CLOSING THE

DIGITAL DIVIDE:
MORE AND BETTER
FUNDING FOR
THE DIGITAL
TRANSFORMATION
OF HEALTH
A Conceptual Framework to guide
investments and action towards health
for all in the digital age
Copyright © 2022, Transform Health. Some rights reserved. This work is licensed under the Creative
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transformation of health. Basel: Transform Health; 2022.”

2
Foreword

The World Health Organization (WHO) recognises the critical role that digital technologies and
health innovation play in helping us achieve the Triple Billion targets and our global goal to achieve
Universal Health Coverage by 2030. The digitalisation of all aspects of our life is happening at an
unprecedented scale. However, the opportunity that this presents to improve the equity, quality
and efficiency of health systems has yet to be fully harnessed - and is unlikely to happen without
increased and improved financing.

We welcome Transform Health’s new report, Closing the digital divide: More and better funding
for the digital transformation of health, which makes a strong case for the necessary catalytic
investment and action to achieve health for all in the digital age. This is a timely and valuable
resource as we reach a stage in global digital health where we are collectively thinking beyond
the introduction of individual digital solutions and services, instead focusing on guidance and
investments in the architecture and the enabling environment for digital transformation of health
systems.

The vision of WHO’s Global Strategy on Digital Health 2020–2025, adopted by Member States
in 2020, is to improve health for everyone, everywhere by accelerating the development and
adoption of appropriate, accessible, affordable, scalable and sustainable person-centric digital
health solutions. Closing the digital divide is a valuable resource to help move us towards the
vision set out in this Global Strategy. By setting out the amount, focus, and nature of investments
needed to support the digital transformation of health systems, with clear recommendations for
all stakeholders, it sets us on a pathway towards achieving these important objectives. With just
eight years to achieve the Sustainable Development Goals, the time for action to achieve health
for all by 2030 is now. WHO is committed to supporting countries to achieve this goal, and we
believe that appropriate, costed digital strategies will accelerate our pace in getting there.

Prof. Alain Labrique

Director, Digital Health and Innovation
World Health Organization (WHO)

3
Contents
Acknowledgements 5

Glossary 6

Abbreviations 9

Executive summary 10

1. Introduction 14

2. Where we are today 19

3. Building the enabling environment for the equitable, inclusive and 31

sustainable digital transformation of health systems
4. Identifying and costing priority digital health investments 42

5. The impact from digital health investments 51

6. A call for increased, better coordinated and aligned investment 61

7. Recommendations 76

Annex I: Development of this report 84

Annex II: Methodology and assumptions underlying the identification and 85

costing of priority digital health investments

Annex III: Health impact case studies – Method and results 94

Endnotes 99

4
Acknowledgements

This report has been developed by Transform Health and guided by Transform Health’s Resource
and Investment Circle and a Global Research Consortium that was established to contribute to the
development of the conceptual framework. The Global Research Consortium brought together
regional and global partners and young people. Members included (in alphabetical order): the
Asia eHealth Information Network (AeHIN); the Digital Connected Care Coalition (DCCC), the
Digital Health and Rights Advisory Group (DRAG), FIND, HealthEnabled, Health Informatics in
Africa (HELINA), the International Digital Health & AI Research Collaborative (I-DAIR), the Joep
Lange Institute, PATH, the PharmAccess Foundation, the Central American Health Informatics
Network (RECAINSA), the World Bank, Transform Health, the World Health Organisation, the GCC
Taskforce on Digital Health Workforce Development (ZIMAM). In addition, we thank the Asian
Development Bank, the Deutsche Gesellschaft für internationale Zusammenarbeit (GIZ), the
Organisation for Economic Co-Operation and Development (OECD), and the Secretariat of the
Governing Health Futures 2030 Commission for their input, review and feedback.

The cost and impact modelling were led by PATH/Digital Square with support from USAID. Digital
Health Partnerships was engaged to spearhead a discussion with private sector stakeholders.
The Joep Lange Institute led the development of the Conceptual Framework together with the
Transform Health Enabling Function.

Transform Health is grateful to Germany’s Federal Ministry for Economic Cooperation and
Development and to Fondation Botnar for their financial support and to all Transform Health
partners that have contributed to the conceptualisation, development and review of this report as
members of Transform Health’s Resource and Investment Circle, the Global Research Consortium
or through bilateral discussions and input. Special thanks also to the partners who provided
examples of digital interventions and their impact on and in health systems.

About Transform Health

Transform Health is a global coalition of organisations, individuals and institutions committed to
achieving universal health coverage through the use of digital technologies and data. To learn
more about Transform Health visit www.transformhealthcoalition.org.

5
Glossary

Access – the availability of telecommunication Data governance – practices for making

devices and services for use by any member of decisions about data throughout its lifecycle
the household at any time. In its broadest sense, to optimise an individual’s, organisation’s or
it considers the economic, sociological and government’s capability for data-informed
psychological factors that influence persons’ policy, strategy and operational management.
opportunities to use technologies (gender,
race, age, place of residence, etc.). Data solidarity – an approach to the collection,
use and sharing of health data that safeguards
Application – a piece of software that can be individual human rights while building a culture
installed on a device to perform one or more of data justice and equity. It ensures that the
digital health interventions. Mobile applications value of data is harnessed for public good.
are add-on software for handheld devices, such
as smartphones and personal digital assistants. Digital health – the field of knowledge and
practice associated with the development and
Broadband – internet connection with use of digital technologies to improve health.
capabilities higher than 256 kilobits per second. Digital health expands the concept of e-health
to include digital consumers, with a wider range
Connectivity – the various physical means to of smart devices and connected equipment.
connect people and machines to the internet
or other communication networks. It usually Digital innovation for health – innovative
requires either a fixed-line or a wireless solution application and use of existing or new products,
via a broadband or dial-up service. processes or models using digital technology
platforms as a means within and across health
Data – information, usually in the form of facts systems and organisations.
or statistics, that can be analysed and used in
decision-making. Digital literacy – the skills, knowledge and
attitudes necessary to successfully use digital
Data equity in health – everyone has access to solutions and effectively understand and utilise
the benefits of data flows, including the poorest, data outputs from such solutions as well as
most disenfranchised and at-risk persons. actively participate in the digital information
For example, robust disaggregated data help society.
improve decision-making at different levels of
the health system to ensure a more equitable Digital public goods – open-source software,
and effective distribution of resources so that data, artificial intelligence models, standards
all people can access the right care at the right and content that adhere to privacy and other
time, no matter where they live. applicable international and domestic laws,
standards and best practices and that do no
harm.

6
Digital technologies – the application of Internet of Things – a system of interrelated
organised knowledge and skills in the form computing devices, mechanical and digital
of electronic, mobile and frontier data-driven machines, objects, animals or people that
technologies to solve health issues and improve are provided with unique identifiers and the
quality of life. Digital technologies for health ability to transfer data over a network without
care encompass definitions, components and requiring human-to-human or human-to-
systems included in digital health, e-health, computer interaction.
m-health (and related terminology). Some
examples include electronic medical records, Interoperability – the ability of different
telemedicine and health management applications to access, exchange, integrate and
information systems. cooperatively use data in a coordinated manner
through the use of shared application interfaces
Digital transformation – the multiple processes and standards, within and across organisational,
of integration of digital technology and data regional and national boundaries, to provide
into all areas of everyday life and the resulting timely and seamless portability of information
changes that they bring. and optimise health outcomes.

Digital transformation of health – the multiple Open source – access to knowledge and tools
processes of integration of digital technology without the need to pay for the knowledge
and data into all areas that affect individual itself, although there may be marginal fees for
and collective health and well-being. This access.
includes the necessary changes in the enabling
environment, including legislation, regulation, OpenSRP – short for “open smart register
funding, public awareness, understanding and platform”, which is an open-source, mobile-
involvement. first platform built to enable data-driven
decision-making at all levels of the health
Digitalisation – the integration of digital system. However, it was designed to address
technologies into everyday life. problems with existing technology solutions
that are fragmented, unscalable, functionally
Digitisation – conversion of analogue data and limited and not interoperable with national-
processes into a machine-readable format. level information systems.

Health data governance – the process of Personal data – any information that relates to
managing and making decisions to guide an identified or identifiable living individual.
the generation, collection, storage and
management of health data through normative, Primary health care – a whole-of-society
actionable and cross-cutting policies, practices, approach to health and well-being centred
standards, benchmarks and regulations. on the needs and preferences of individuals,
families and communities. It provides whole-
Information and communication technologies person care for health needs throughout the
– the set of technologies developed to store, lifespan, not just for specific diseases, ranging
send and receive information from one place from promotion and prevention to treatment,
to another. rehabilitation and palliative care.

7
Principles for Digital Development – nine Telemedicine – a subset of telehealth that refers
guidelines designed to help integrate solely to remote clinical services.
best practices into technology-enabled
programmes that are intended to be updated Universal access – reasonable telecommuni-
and refined over time. They offer guidance cation access for all persons. It includes univer-
for every phase of a project life cycle and are sal service for those who can afford individual
part of an ongoing effort among development telephone service and widespread provision of
practitioners to share knowledge and support public telephones within a reasonable distance
continuous learning. of others.

Principles of Donor Alignment for Digital Universal health coverage – all individuals and
Health – 10 principles that are meant to communities receive the health services they
guide investments in countries’ digital health need without suffering financial hardship. It
systems by aligning with countries’ digital includes the full spectrum of essential, quality
strategies, by working in a collaborative way health services, from health promotion to
with development partners and governments prevention, treatment, rehabilitation and
and by developing global goods. palliative care across the life course.

Soft infrastructure – programmes and Young people – a heterogenous group with

resources in an ecosystem that provide both significant differences across age, gender,
physical assets, such as specialised buildings ethnicity, religious identity, sexual identity,
and equipment, as well as non-physical assets, economic status and other factors. There are
such as communication, regulations, the also differences in definitions of young people.
financing of these systems and the training For the purpose of this report, we define “young
and mentorship of professionals. people” or “youth” as individuals between the
ages of 15 and 30 years, unless otherwise stated.
Sustainable Development Goals – 17 goals
adopted by the General Assembly of the United
Nations in 2015 to achieve a better and more
sustainable world for all by 2030. Sustainable
Development Goal 3 (Ensure healthy lives and
promote well-being for all at all ages) includes
a target to achieve universal health coverage by
2030.

Telehealth – the use of mobile and

telecommunications to deliver health services
outside of traditional health care facilities.
Telehealth refers to clinical and remote
non-clinical services, including providing
training and continued medical education for
practitioners.

8
Abbreviations

CDC Centers for Disease Control and Prevention

COVAX COVID-19 Vaccines Global Access
FIND Foundation for Innovative New Diagnostics
Gavi Gavi, the Vaccine Alliance
GDHI Global Digital Health Index
GIZ German Agency for International Cooperation
ICT Information and communication technologies
IDSR Integrated Disease Surveillance and Response
IMCI Integrated Management of Childhood Illness
IT Information technology
LiST Lives Saved Tool
NGO Non-government organisation
OECD Organisation for Economic Co-Operation and Development
OpenSRP Open Smart Register Platform
PPP Purchasing power parity
SDG Sustainable Development Goal
SORMAS Surveillance, Outbreak Response Management and Analysis System
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization

9
Executive Summary

The world’s health systems are changing ers and include strong accountability mecha-
rapidly, driven by the introduction of digital nisms will shepherd a digital transformation
technologies, artificial intelligence and the use that responds to the concerns, expectations
of large data sets. The digital transformation and needs of a broad spectrum of stakehold-
has the potential to expand access to health ers. This encompasses civil society, patient
care and accelerate progress towards the groups, health professionals, academia, young
Sustainable Development Goal target of people, women and other traditionally mar-
reaching universal health coverage by 2030. ginalised communities, as well as the private
sector, under the convening and leading role of
We have reached a stage in the digital health governments. This would also help safeguard
journey where we need to think beyond against unwarranted or unanticipated exclu-
enhancing health systems through the sions or negative consequences of that digital
introduction of individual digital technologies transformation. This means involving people
and to instead consider the digital in the design and the oversight of the digital
transformation of health systems in its broader transformation, understanding their needs and
sense. We need to remove the underlying responding to their concerns about existing
obstacles and challenges to sustainability and or potential violations of privacy and human
scale. We need to focus on the actions and rights.
the investments that are necessary to drive
a more equitable, inclusive and sustainable Countries must develop costed strategies to
transformation of health systems in low- and guide the digital transformation of their health
lower-middle-income countries. system and governments must be in the
driver’s seat of this complex, fast-moving and
The past 20 years have seen renewed focus challenging process, with other stakeholders
on health governance and have led to a deep- aligning with and supporting their plans.
er appreciation of the impact of good gover- This also includes promoting and expanding
nance, in its broadest sense (to include legisla- digital connectivity and digital literacy across
tion, regulation and funding, as well as political societies; for health workers across all cadres,
leadership, oversight and accountability) on including community health workers; and also,
health care delivery across all tiers of the health for patients, policy-makers and all people who
system. An inclusive governance structure and will interact with a digitalised health system.
processes that are transparent, ensure the
meaningful engagement of diverse stakehold-

10
Little information exists about the financial The total projected cost represents approxi-
resource requirements or how funding should mately 1% of the annual government health
be invested and in what sequence to achieve spending of the group of low- and lower-mid-
a successful digital transformation of health dle-income countries. It is not unreasonable
systems. In this Conceptual Framework, we to assume that, on average, 60–70%3 of this
have identified and costed nine priority digital amount can be met from national resources,
health investment areas, selected on the basis of with the remainder to be externally supported.
input from more than 350 global stakeholders. While countries must take the lead in funding
We have also identified other areas that will their health system, in many resource-con-
require greater investment to ensure that the strained contexts, donor agencies, philanthrop-
enabling environment will facilitate the digital ic organisations and the private sector are also
transformation in an equitable, inclusive and critical. The relatively modest scale of the need-
sustainable manner. ed funding should encourage more donors to
reassess the potential of catalytic investments
By modelling the estimated cost of these nine in the opportunities presented. To ensure that
investment priorities in low- and lower-middle- the digital transformation of health systems is
income countries1, we have come up with an funded and supported in the most effective
indicative figure for resource needs for a digital manner, coordination and alignment of inter-
transformation of health systems in those national investments are necessary.
countries, including five-year cost projections
for each area.2 Based on this modelling, we The digitalisation of all aspects of life, including
estimate that an investment of US$ 12.5 billion health, will progress relentlessly. But this
is needed for the nine priority investment areas progress must be led and guided by a clear and
in 78 low- and lower-middle-income countries inclusive process if it is to lead to better health,
over the next five years, or approximately US$ greater inclusion, reduction of inequalities and
2.5 billion per year on average. closing the growing digital divide. Even modest
additional investments during this period,
Health infrastructure accounts for approxi- if well directed, have the potential to build
mately 75% of the total projected investment. stronger and more resilient health systems.
But this only includes health sector costs
(health record digitisation, wide and local area
networks within facilities and information and
communication technology equipment need-
ed at facilities) and not the general investment
required to increase digital connectivity or us-
age among the population, which must also
be prioritised. Operational costs, which include
ongoing expenses for maintenance, equip-
ment replacement, refresher training, software
licensing, project management and help-desk
support and make up half of the total project-
ed costs, are often not fully accounted for in
current costing analyses and are absent from
most data sources. They are included in this in-
vestment estimate.

11
This Conceptual Framework outlines the amount, focus and nature of the
investments needed to support the equitable, inclusive and sustainable digital
transformation of health systems in low- and lower-middle-income countries
and offers recommendations for how that transformation should occur.

Recommendation 1 – More investment from domestic and international

sources. Governments and international donors should prioritise funding to
support low- and lower-middle-income countries in digitally transforming their
health system, ensuring it is equitable, inclusive, sustainable and protective
of people’s interests, their right to health, their privacy and their capacity to
participate in its governance. Although we have projected an average funding
need of US$ 2.5 billion per year for the next five years for nine priority digital
health investments areas for these countries, the true investment requirement
will ultimately be determined country by country and based on costed plans.
It will need to be complemented by wider investment to increase digital
connectivity and usage among the population, as well as investments to
address the broader enabling environment.

Recommendation 2 – Better coordinated and aligned investments.

International donors and the private sector should ensure that their
investments are coordinated and aligned with national priorities. This should
include identifying and strengthening systems and processes that improve
the coordination of funding. Without it, there is a risk of fragmentation,
duplication and waste. At national level, there is a need for coordination among
stakeholders and international donors through transparent processes and
under the leadership of the government. The widely endorsed Principles for
Donor Alignment for Digital Health provide the blueprint for this coordinated
action and should be fully adhered to and monitored.

To enhance transparency and accountability, there is also a need for multilateral

development institutions to introduce tools at national scale that track and
publish data on funding for digital health as part of their wider health investment.
In addition, WHO should fulfil the wide-ranging strategic, normative and
technical role envisioned for the organisation at the World Health Assembly
meeting in 2018. In this capacity, WHO must monitor the needs and flow of
funds for the digital health transformation.

12
Recommendation 3 – A costed digital health strategy and investment road
map. Countries must each develop an inclusive digital health strategy as an
integral component of their universal health coverage and health system-
strengthening agenda. The strategies must be aligned with the country’s
digital health maturity levels, and they must promote interoperable solutions
for connectivity, capital investment, data governance, legislation and
regulation, literacy and workforce. These solutions need to be developed in
an inclusive and participatory manner, with sufficient time for consultation
with different stakeholders, including civil society, youth, women and
marginalised and hard-to-reach communities, as well as health workers
at all levels of the health system. These strategies need to be costed and
accompanied by a prioritised and sequenced investment road map that lays
out the different sources of funding as well as the gaps.

Recommendation 4 – A robust regulatory f ramework and policy

environment. National governments must prioritise establishing a legislative
and regulatory framework and the necessary policies to guide the digital
transformation of their health system so that it is inclusive, equitable and
sustainable. This process must be based on multistakeholder engagement
and include the broad participation of civil society, including youth, women,
older people, people living with disabilities and marginalised and hard-to-
reach communities. This needs to lay the legal foundations in terms of health
data use, privacy, digital literacy and the policies for what kind of digitalised
health system a country needs to ensure universal health coverage. A
transparent public policy environment increases planning and investment
certainty for international donors and the private sector and clarifies the
incentives and expectations.

Recommendation 5 – Mechanisms for meaningful multistakeholder

engagement. For a digital transformation to be effective in improving health
outcomes and accelerating progress towards universal health coverage,
civil society, including young people, women, older persons, persons with
disabilities and marginalised and hard-to-reach communities, needs to be
involved at all levels of planning, strategy, execution and monitoring of the
transformation. Such participation needs to be supported financially to
ensure that communities across all strata of society are represented and can
hold decision-makers and service providers accountable.

Recommendation 6 – Improved digital connectivity. There is urgent

need for all stakeholders – national, international, public and private – to
prioritise strategic, targeted and coordinated actions to close the divide
in digital access. This is a prerequisite for equitable access to technology-
enabled health services. This means addressing coverage gaps, affordability
and digital literacy. It requires political will at all levels and civil society
engagement to mobilise policymakers and to generate public awareness.
If ignored, the divide in connectivity will widen the health equity gap and
further marginalise already disadvantaged populations.

13
01
INTRODUCTION
Digital transformation has the potential to Across many jurisdictions and in the absence
accelerate universal health coverage and ensure of strong regulation, digital technology
that lagging countries accelerate progress multinationals wield significant influence over
towards their Sustainable Development Goal the population’s access to information. They are
target (3.8) by 2030. The increased use of shaping the way this information is collected,
digital technologies offers many possibilities to used, stored and disposed of. Some progress has
improve the health outcomes of all people. If been made to regulate data use, for example,
unchecked or poorly regulated, however, it has in the European Union4. And principles5 and
the potential to exacerbate the existing social recommendations6 have been developed to
inequalities and exclusions. guide the governance of health data. But the
task of implementing robust and equitable
To ensure that digital technology drives access data governance regulation is daunting for
and inclusion rather than becoming another many countries. Adding to this complexity is
barrier to health services, governments, donors, the enormous power that the control of the
civil society and the private sector must work data and information provides governments
together to harness its potential for delivering and the private sector. The possible misuse of
health care for all. this power by authoritarian regimes cannot
be overlooked and must be considered when
As internet coverage grows and more people digital systems for collecting personal health
get connected, access to information and data are developed.
services and the efficiency and effectiveness of
these services to respond to the health needs We have reached a stage in our digital health
of the population is improving constantly. journey where we need to think beyond
However, across many countries this growth has enhancing health systems through the
been uneven. Many interventions to digitalise introduction of digital technologies. We now
health systems have been characterised by must consider the digital transformation of
siloed approaches and interventions, a lack of health systems in its broader sense and address
coordination and poor adoption at the front- the underlying obstacles and challenges to
line or at the community level. The way many sustainability and scale. We must focus on
digital interventions have been implemented the actions and the investments that are
also places high transaction costs on health needed to drive a more equitable, inclusive and
systems because health professionals are sustainable digital transformation of health
requested to adopt more tools and use different systems.
systems to respond to different populations or
different health needs.

15
What does digital transformation mean when A 2018 World Health Assembly resolution char-
we speak about health systems? Transform acterises the digital transformation of health
Health draws on “The Lancet and Financial as a systemic and fundamental change in how
Times Commission on Governing Health health care will be thought about and delivered
Futures 2030: Growing Up in a Digital World” and in the future.8 The World Health Organization’s
its general definition for digital transformation: (WHO) Global Strategy on Digital Health 2020–
“the multiple processes of integration of digital 2025, which grew out of this resolution, stresses
technology and data into all areas of everyday that “digital health should be an integral part
life, including health, and the resulting of health priorities and benefit people in a way
changes that they bring.”7 Applied to health that is ethical, safe, secure, reliable, equitable
systems, the digital transformation necessarily and sustainable. It should be developed with
encompasses the enabling environment that principles of transparency, accessibility, scal-
touches on different social and political spheres ability, replicability, interoperability, privacy, se-
and involves multiple sectors and stakeholders. curity and confidentiality.”9

16
A Conceptual Framework
to guide future action and
investment
This Conceptual Framework looks at how • development of transparent national strat-
systematic and coordinated investment – by egies, costed plans and public accessibility;
governments, international donors and the • investment in digital skills across the health
private sector – can overcome many challenges system;
crowding the path towards an equitable, • incentives and guidance to enable private
inclusive and sustainable digital transformation. sector investment in support of a national
digital strategy.
It takes as its starting point and foundation
the WHO’s Digital Health Strategy and the It highlights the importance of engaging and
Governing Health Futures 2030 Commission’s serving traditionally marginalised communities
report10. The process to develop this Conceptual and groups, such as women, youth, older
Framework involved interviews with experts and people, persons with disabilities, remote or rural
partners and other research led by Transform populations and communities of people living
Health’s regional and youth partners in Asia; with communicable or noncommunicable
Eastern Mediterranean; Eastern, Southern, diseases.11
West and Central Africa; and Latin America. It
also included global cost and impact modelling In the Conceptual Framework, we chose to
and discussions with development partners highlight the situation and the expectations of
and international donors in standing forums young people. While Transform Health advo-
and dedicated meetings (Annex I). cates for the needs of all marginalised groups
to drive the digital transformation, the part-
The Conceptual Framework describes an nership with Young Experts: Tech4Health12
approach that emphasises building up and provides access to the perspectives of young
supporting the enabling environment through: people at the global level. Young people are
• an emphasis on expanding access and use a heterogenous group with significant differ-
of digital devices and the internet among ences across age, gender, ethnicity, religious
the whole population; identity, sexual identity, economic status and
• capacity and modalities for putting in place other factors. For this report, we define “young
a regulatory and policy environment to people” and “youth” as individuals aged 15–30
steer digital health transformation; years, unless otherwise stated.
• support for and engagement of a broad
array of stakeholders, including health This Conceptual Framework frames the
workers, parliamentarians, civil society, thinking on how investments can be used to
communities and citizens seeking health steer and shape low- and lower-middle-income
information and care, to guide, participate countries’ digital health transformation. It
in and oversee these modalities; assesses the scale of meaningful investment

17
required in these countries over the coming Following this introduction, Chapter 2 describes
five years. It explores some of the investment the status of the digital transformation of health
challenges and their consequences in and the main processes, trends and tools within
relation to digital health care in low- and the global landscape. Chapter 3 discusses the
lower-middle-income countries and makes necessary conditions that need to be in place
recommendations on how governments, so that a comprehensive national strategy on
donors and other stakeholders can collaborate digital transformation can be resourced and
to ensure that digital technology supports the implemented successfully. Chapter 4 presents
ambitions to achieve universal health coverage the outcome of the modelling analysis of
by 2030. The Conceptual Framework argues the projected investment needed for nine
that an investment of US$ 2.5 billion a year priority areas that would promote the digital
over the next five years, with ongoing costs transformation of the health system in 78
of US$ 2 billion in the sixth year and beyond, low- and lower-middle-income countries.
could support low- and lower-middle-income Chapter 5 looks at the potential impact of
countries13 achieve the digital transformation of digital technologies and artificial intelligence
their health system. It also recognises that this on health outcomes. Chapter 6 lays out the
must be complemented by greater investment case for more and better aligned resources for
to increase digital connectivity and use among the equitable, inclusive and sustainable digital
populations and to strengthen the enabling transformation of health systems. And finally,
environment. Chapter 7 presents the recommendations.

BOX 1

Explaining digital health and

digital transformation
What is digital health? What is the digital transformation of health?
The field of knowledge and practice associated The multiple processes of integration of digital
with the development and use of digital technology and data into all areas that affect
technologies to improve health. Digital health individual and collective health and well-being.
expands the concept of e-health to include This includes the necessary changes in the
digital consumers, with a wider range of smart enabling environment, including legislation,
devices and connected equipment. It also regulation and funding as well as public
encompasses other uses of digital technologies awareness, understanding and involvement.‡
for health, such as the Internet of Things, artificial
intelligence, big data and robotics.* What is data solidarity?
An approach to the collection, use and sharing
What is digital transformation? of health data that safeguards individual human
The multiple processes of integration of digital rights while building a culture of data justice
technology and data into all areas of everyday and equity and ensuring that the value of data is
life and the resulting changes that they bring.† harnessed for public good.†

Source:
*=WHO, Global strategy on digital health 2020–2025, 39–40;
†= Kickbusch et al., “The Lancet and Financial Times Commission on Governing Health Futures 2030: Growing Up in a
Digital World,” 1730.
‡ = Transform Health

18
02
WHERE WE
ARE TODAY
From ad hoc digital
solutions to a
national, strategic
approach
The potential of digital technologies to provide a proliferation of uncoordinated digital
improvements and efficiencies in health health projects, denoting a fragmented
care has been evident for at least 20 years. system, leading to unnecessary duplication
Its uptake, however, has been relatively slow, of expenditures and data silos that hinder
uneven, unsystematic and mostly limited to their systemic use.
individual products, services and processes, • In Asia, systemic deficiencies, such as
such as digitalising the supply chain for a few silos in data, poor integration, and lack of
health products or, at most, a procurement interoperability within and beyond the
system. This typically has been spearheaded public health system continues to be a
by a specific disease response, for example, a challenge in many countries.
national malaria programme’s supply chain • In the Eastern Mediterranean region,
may be digitalised. This leads to different sporadic and isolated digital health
disease programmes using different systems interventions risk leading to system
that are not interoperable. That practice, along fragmentation and double spending.
with a large number of pilot projects that do
not progress to a system-wide or national scale The many isolated pilot projects and often
adoption, lead to a fragmented landscape, with incompatible initiatives that have emerged
health care providers often compelled to learn in the absence of national plans lead to an
how to use multiple systems.14 expensive and fragmented approach to the
digitalisation of health services. Most countries
This experience has been shared across the accept that they need a comprehensive,
countries and regions covered by our research, strategic approach to the digital transformation
which identified some of the following of their health sector. Our research shows
challenges: that many countries have developed some
• In Cameroon, many digital applications are framework for digital planning within their
in use at the community and health facility overall national health strategy or strategy to
levels, as well as at the district, regional achieve universal health coverage. However,
and national levels, but without any overall the quality and level of detail of these plans vary
coordination or selection based on national greatly. Inclusion is not well reflected in these
need or suitability. digital planning processes. All regions reported
• In Kenya, a total of 123 different digital little to no engagement of civil society, let alone
transformation projects were identified, marginalised groups in the decision-making
with 230 different organisations active processes around the digital transformation of
within the country’s digital health space. health.
• Latin America and the Caribbean face

20
Digital health
maturity

A country’s capacity for digital transformation developed an extension to the GDHI model
depends on its levels of connectivity, penetration using the World Economic Forum’s Network
of digital tools (such as computers, tablets, Readiness Index indicators for the political and
laptops and smartphones) in the population, regulatory environment, infrastructure and
digital literacy and financial resources. In digital context and skills (Figure 1). In this model,
order to raise a country’s digital maturity the lowest-ranking digital health maturity
level, it is imperative that political leaders and countries are a level 1, with the highest at level
parliamentarians understand the potential 5. Digital maturity does not always correlate
benefits of the digital transformation and its with income classifications.16
risks. The current level of that understanding
varies greatly from country to country. If a This classification found that 150 million
digital transformation is to accelerate health people live in the lowest maturity tier (level 1).
equity, differentiated approaches, based on More than 5 billion people live in levels 2 and
each country’s “digital maturity” level, are 3, with roughly 1.5 billion people in the top two
needed. maturity tiers, levels 4 and 5. For the 1.5 billion
people living in high-maturity countries, digital
Digital health maturity models help to transformation is well under way. However,
understand which national digital strategies as the COVID-19 pandemic has revealed, the
are the most useful. These diagnostic wealthiest countries also face challenges in the
assessment tools assess the current state governance of data among other things.
of a country’s political, infrastructural and
educational environment for the digital
transformation of health care. Several models
exist, but they largely follow similar systems
of ranking countries’ digital maturity. The
Global Digital Health Index (GDHI) is a broad
collaborative effort of different partners that
has built a five-point scale using the eHealth
Building Blocks of WHO and the International
Telecommunication Union.15 Digital Square

21
 Figure 1 Global market maturity map

Market Maturity Legend

1 5

Digital Square segmented all countries in the world into five digital health maturity market levels
to better understand end users’ needs and digital health product requirements. The market
segmentation framework leverages data from 25 early-adopter countries on the Global Digital
Health Index (GDHI). For the remaining countries, Digital Square developed an extension to the
GDHI based on 17 World Economic Forum Networked Readiness Index indicators. These indicators
include political and regulatory environment, infrastructure and digital context and skills. Lower
digital health maturity markets (levels 1–3) completely lack digital policies or have planned policies
that are not yet implemented. They also likely have 2G infrastructure and variable electricity. The
workforce has less digital literacy skills. In contrast, higher maturity levels have digital policies that
are enforced. In addition, they are more likely to have 3G infrastructure and reliable electricity
with a digitally literate workforce.

Source: Digital Square, “Market Analytics”, https://digitalsquare.org/market-analytics.

22
Broadband coverage
is improving, but
access to digital tools
is lagging
Mobile network coverage (3G or higher) – the The situation, however, is not matched by
measure of who lives within the footprint of a usage. Despite living in areas with broadband
mobile broadband network – has expanded coverage, a large part of the global population is
rapidly in recent years. In 2021, the International still not online because they do not have access
Telecommunication Union estimated that 95% to digital tools.17 An estimated 2.9 billion people
of the world’s population was within broadband are offline,18 including 1.7 billion people in the
coverage, with Africa, the continent with the Asia–Pacific region, 29.1% of the population of
lowest rate, reaching 82%. This bodes well for China19 and 50% of the population of India.20 In
rolling out digital tools and services across the Africa, 738 million people remain offline – that’s
health system. In most countries, even district two out of three people unconnected, which
health posts are likely to be connected to the increases to around five out of six people in
internet through mobile broadband. rural areas.

Figure 2 Internet use versus mobile broadband coverage

INDIVIDUALS USING THE INTERNET POPULATION COVERED BY AT LEAST 3G

MOBILE NETWORK
Per 100 inhabitants
Per 100 inhabitants
100

80

60

40

20

0
2015 2016 2017 2018 2019 2020 2021 2015 2016 2017 2018 2019 2020 2021

Developed Developing

Least Developed Countries (LDCs) Africa

Source: Based on ITU’s statistics from Measuring digital development: Facts and figures 2021.

23
This gap between coverage and access – • The Botswana Communications Regulatory
and the critical role that political will plays in Authority boasted that as of 2020, the
overcoming this gap – was highlighted in our national fibre coverage was more than 9000
research: kilometres, covering cities, major towns and
villages, with 164 out of a target of 206 areas
• In Kenya, investments to increase internet covered.
connectivity have been made by state • In 2021, Malawi launched the second phase
and non-state actors. Fibre Optic cables of its national fibre backbone to drive digital
have been laid along major highways transformation. The project includes 3000
in most counties by the Ministry of ICT, kilometres of fibre optic cables connecting
Innovation and Youth Affairs. In the 2022– homes and businesses across the country.
2023 Digital Master Plan, the Kenyan
Government announced plans to deploy
100 000 kilometres of fibre optic cables to
schools, health facilities and government
institutions.21

24
Uneven access, affordability
and digital literacy are
considerable challenges
Although many countries are now in the • Approximately 200 million people lack access
situation that their mobile broadband coverage to basic digital infrastructure in Latin America
allows them to plan for a rapid digitalisation and the Caribbean, and others have access,
of their health system, significant segments but the service is of poor quality and/or very
of their population are not able to connect to expensive. This means that more than a third
or benefit from basic internet content. This of households still do not have an Internet
means many are not able to make use of connection. The digital divide between rural
digital services for health care, with the risk of and urban areas in Latin America and the
increasing health inequalities. Caribbean remains significant, with 67% of
households in urban areas having internet
The previous examples of investments towards connectivity while only 23% of households in
digital infrastructure by national governments rural areas are connected.
in Eastern and Southern Africa are a crucial
starting point for promoting inclusion because Our research found several countries facing
most aim to achieve last-mile connectivity. At significant barriers, such as non-existent or
the same time, access and therefore usage are unreliable power supply, network outages,
lagging: lack of equipment maintenance and highly
uneven digital literacy. Informants in Eastern
• In Malawi, for example, only 44% of the and Southern Africa noted that despite the
population possesses the foundational skills introduction of digital systems, health workers
required to leverage digital technology, and still capture data on paper primarily and resist
60% of the population lacks the competency the digital systems, viewing them as a waste
to operate a computer or access the internet of time. The main reasons for this resistance
on their mobile device. This situation is not include unreliable systems due to downtime
unique to Malawi but is evident across Eastern and difficulties navigating the sometimes
and Southern Africa and in sub-Saharan complex systems.
Africa. According to the World Economic
Forum, eight of the ten most disconnected
countries are in sub-Saharan Africa.

25
 Closing the global
digital divide
Figure 3 Percentage of the population using the internet, 2020

Internet use share (%)

0 - 20

20 - 40

40 - 60

60 - 80

80 - 100

n.a.

Source: Based on ITU’s statistics from Measuring digital development: Facts and figures 2021.

26
Closing the use gap will be considerably harder “One of the key objectives of
than ensuring coverage of broadband networks.
This is because the main and long-entrenched
digital health transformation
barrier to getting people online is the same is to achieve health equity,
factor that prevents people from accessing which is the absence of unfair,
health services in the first place: financial
hardship. This is exacerbated by the fact that
avoidable or remediable
data plans are generally comparatively more differences in health care
expensive in countries with lower incomes than access and health outcomes
in wealthier ones.22
among groups of people.”
Gender, age, health status, whether one lives
– Conceptual Framework research, Eastern
in rural or urban settings, education levels and
Mediterranean
digital literacy, also determine who has access
to a digital device and who doesn’t. These
The United Nations High-level Panel on Digital
factors affect the same groups that tend to fall
Cooperation, convened by the United Nations
through the cracks of most health systems.
Secretary-General in 2019, makes clear that
Cultural differences, resistance or community
marginalisation is an expanding problem.
unwillingness to accept and adopt digitalisation
also can be a barrier.

People who lack safe and affordable access to digital

technologies are overwhelmingly from groups who are
already marginalised: women, elderly people and those with
disabilities; indigenous groups; and those who live in poor,
remote or rural areas. Many existing inequalities – in wealth,
opportunity, education, and health – are being widened
further.
– United Nations High-Level Panel on Digital Cooperation, 200923

27
 BOX 2

From our youth-led

engagement process
Young people tend to be more digitally To the extent that young people, more than
literate and better at finding information and older generations, rely exclusively on social
negotiating digital environments that may be media for information, they struggle with
less intuitive and difficult to understand for separating valid from false information.
older persons. Yet, they often face challenges They display a higher level of distrust of
in accessing traditional quality health care official sources of information, and they
services due to social, cultural and/or legal are concerned about data privacy. There is
barriers that limit their agency, especially therefore a danger that increasing access to
in sensitive health areas like sexual and digital sources of information on health may
reproductive health and mental health. With increase misinformation and confusion and
the advent of digital health care, they are now reduce trust among young users.
able to access more information, support and
services without experiencing discrimination
or stigma.

If we are going to manage a digital “This digital divide makes

transformation of health in a way that benefits
everybody, we will need to overcome the
inequality worse. The vast
challenge of ensuring that everybody can majority of the world’s
connect to digital services. And we will have unconnected people live in low-
to safeguard against unintended harmful
consequences as the health sector moves
and middle-income countries.
rapidly to introduce digital technologies and And access is not the only issue.
artificial intelligence, so that digitalisation does We know that the transformative
not inadvertently become a means of excluding
populations from health services rather than a
power of digital technology is
driver of greater inclusion. sometimes misused, often in
ways that reinforce inequality
and exclusion. Digitalisation is
a double-edged sword: used for
both good and ill.”

– Organisation for Economic Co-operation and

Development, 202124

28
Tools, guidance and
assistance are growing

WHO’s Global Strategy on Digital Health 2020– Major bilateral and multilateral funders are
2025 provides a framework for how countries dedicating significant funding to countries
should go about a digital transformation. to support their digital transformation,
A central objective in WHO’s strategy is to either directly or through non-government
promote “people-centred health systems that organisations or consultants. These funders
are enabled by digital health”. Building solutions include the World Bank; the United States
around people’s needs and rights – rather than Agency for International Development (USAID);
being driven by technological opportunity – is the Global Fund to Fight AIDS, Tuberculosis
the main purpose of all digital transformation and Malaria; Gavi, the Vaccine Alliance; the
efforts. German Development Cooperation (GIZ); and
regional development banks. Although the
Through its headquarters and regional and scale is hard to assess, significant investments
country offices, WHO provides countries with in digital technologies are taking place
support and advice in their efforts to develop through traditional investments for health.
and implement a national digital health Most health funds and initiatives are already
strategy. WHO acknowledges25 that while they investing heavily in digitalising their systems in
take a supporting, coordinating and norm- programme countries. However, our research
setting role, they are operating within an could not find evidence of the systematic
already busy environment where other actors programming of and dedicated funding for
also have important roles. Low- and middle- inclusive governance processes, let alone
income countries now have a broad range of mobilisation and engagement of stakeholders
organisations, institutions and donor agencies at the community level. This is an important
to draw support from as they embark on their gap, given the critical role of civil society and
digital transformation journey. community engagement in health planning,
promotion, emergency response, governance
Some of these organisations focus on better and accountability.
structuring the digital transformation by
assisting low- and middle-income countries
in developing a digital health transformation
strategy, issuing guiding documents and
manuals, suggesting how to prioritise
investments, assessing the need to support
and to regulate the private sector, generating
research and organising platforms for accessing
and sharing data for health research.

29
Private sector engagement
is evolving

A myriad of smaller initiatives within the area of As governments digitalise their health services
digital technologies and artificial intelligence and as open-source communities and large
for health that have relevance for low- and companies start offering digital health and
middle-income countries are increasingly wellness services in parallel, countries are
being developed and marketed by the private increasingly facing complex and often fraught
sector. These range from apps and other questions about ownership and privacy of data.
software for self-testing for different diseases These are issues that an increasing number
and conditions and collecting and organising of countries are wrestling with. Starting an
patient data to phone-based health insurance informed national debate early and seeking best
and payment systems. The rapid development practice from other countries is a good first step
of wellness and health monitoring apps and to address these issues. Developing a robust
e-health systems aimed at high-income regulatory framework and policy environment
populations are spreading globally and is essential to manage the challenges as they
inspiring innovation in the use of technologies emerge. This is one particular area where
to track health and facilitate access to e-health international assistance may be an important
services in low-and middle-income countries. supplement to local expertise and resources.
The market for consumer-focused digital health
products and services has traditionally been
seen as too small for the largest information
technology companies to invest in low- and
lower-middle-income countries. Instead,
private sector investment and engagement in
these countries has mostly relied on developing
technologies funded by donors. However, this
situation is changing rapidly.

30
BUILDING THE ENABLING
ENVIRONMENT FOR THE
EQUITABLE, INCLUSIVE

03
AND SUSTAINABLE DIGITAL
TRANSFORMATION OF
HEALTH SYSTEMS
Digital transformation is not simply about It is imperative to ensure the meaningful en-
ensuring that stand-alone digital solutions gagement of civil society and communities,
can be technically connected. It is also about including representatives of the most mar-
transforming health systems through digital ginalised and vulnerable persons as well as
means in a way that is equitable, inclusive and health workers, in the digital transformation.
sustainable. It must accommodate future needs, They must be empowered to contribute to this
technological innovation and human rights. change and to hold decision-makers account-
And it must be backed by the necessary scale able.
of investment to deliver on people’s and health
professionals’ needs. Digital transformation is The following sections outline essential ele-
complex and challenging and goes beyond the ments that are needed. The specific needs of a
remit of one single ministry (health). It requires country are of course context-specific and may
a “whole of government approach”, which in go beyond this core list.
turn must include all stakeholders.

There is clear recognition of the vital importance

of a systematic, national strategic planning
process for this transformation.26 Governments
and donors must also be cognisant of the
potential consequences of a rushed and
haphazard deployment of digital technologies
in health care without proper ethical and
political frameworks, good governance and
conducive regulation in place.

32
Inclusive
governance

An inclusive governance structure and leadership is essential, this leadership should be

processes that are transparent, ensure the challenged when needs arise, encouraged and
meaningful engagement of diverse stakeholders scrutinised by stakeholders knowledgeable
and that include strong accountability of and directly engaged and affected by the
mechanisms, will help ensure a digital transformation, including communities and
transformation that responds to the concerns, health workers. Our research suggests that
expectations and multiple perspectives of the currently many actors and stakeholders are not
full population. This includes civil society, patient engaged.
groups, health professionals, academia, young
people, women, traditionally marginalised “While there is a vibrant digital
communities as well as the private sector, with
government in a convening and leading role. and e-health ecosystem in
This will help safeguard against unwarranted the country, there is limited
or unanticipated exclusions or negative
participation of patients and
consequences of that digital transformation.
Looking at additional investment in the digital health workers in health facilities
transformation of health systems, it is critical to in the process of digital and
begin with fostering leadership and governance.
e-health transformation in the
This includes the establishment of a high-level
coordinating body under the leadership of the country.”
Ministry of Health, with the mandate and the
– Conceptual Framework research, Asia
power to define the purpose, goals and direction
of the digital transformation of health systems
Realising the commitment to “design with
and to oversee the progress of this work. This
the user” and to “understand the existing
body must involve the planning and finance
ecosystem”, which is summarised in the
ministries and those arms of the government
Principles for Digital Development,28 requires
that oversee ICT, research, education and data
governments to have the network and the
security. The recent cross-country analysis
trust to engage diverse stakeholders and for
conducted as part of the Data Use Acceleration
communities to be empowered and have the
and Learning initiative in Burkina Faso,
platforms to channel their expertise and their
Ethiopia, Malawi, South Africa and the United
expectations into decision-making forums.
Republic of Tanzania underlined the need for
– and the role of – such cross-ministerial and
The youth consultations for this report
multistakeholder governance.27
unequivocally called for inclusion of young
people in all aspects of the digital health
Building on this, the process of the digital
transformation, leveraging their unique
transformation of health systems needs to be
position as actors and consumers of digital
grounded in national debates, hearings and
health care.
consultations, and its decision-making process
must be transparent. Although political

33
Robust regulatory
frameworks

The COVID-19 pandemic has increased people’s The tracking, influencing and oversight of
attention and political awareness in relation to digital transformation and how data is being
the collection, processing, storage, analysis, governed is gaining political attention. The
use, sharing and disposal of health data. One Digital Health and Rights Project recommends
of the most common themes observed across learning from the model of the HIV response,
the youth consultations in different countries is whereby “community-led networks of people
the lack of trust in data protection. Repeatedly, living with and affected by HIV have translated
the request for more personal details was seen arcane human rights law, medicine and
as an encroachment on an individual’s privacy pharmaceutical knowledge into user-friendly,
that potentially exposes that person’s identity. actionable language and have used this
This was cited as a major concern. process to mobilise marginalised groups and
have a meaningful say in decision-making”.31
A growing number of organisations, including
from civil society, are working on the issue of The digital technology revolution over the
human rights and digital technology with past three decades has been characterised by
recommendations and guidance to strengthen technological advances outpacing legislative
the governance of health data. In 2021–2022, and regulatory processes. As we have seen,
Transform Health, for example, stewarded governments and lawmakers constantly play
the development of rights-based Health catch-up with industry but often not before
Data Governance Principles, which centre on the negative consequences of unregulated
protecting people, promoting health value commercial application of new technologies
and prioritising equity. Developed through an have become apparent and nearly impossible
inclusive, bottom-up process, the principles to reverse.
combine contributions from more than 200
experts across diverse geographies, sectors and Areas in which regulation is particularly needed
stakeholders and have so far been endorsed by are linked to the ownership and use of data,
more than 130 organisations.29 the nature of and basic principles for national
health insurance systems and the private
The Organisation for Economic Co-operation sector’s role in providing individualised heath
and Development (OECD) has a Council care and digital health solutions, along with
Recommendation on Health Data Governance the conditions under which these solutions can
that all its member countries are expected be delivered. At a policy level, guidance on the
to implement. This legal instrument aims to use of open source versus proprietary software,
guide “in setting the framework conditions for the compatibility of data, standards of care
enabling the availability and use of personal and an ethical framework for digital platforms
health data to unlock its potential”.30 are among the many areas that would need
formulation.

34
By necessity, this work will be a complex process country. Countries should map their existing
of building a vehicle while moving at high legislation, identify gaps and establish a priority
speed, and countries will need to be pragmatic order in which to develop the regulatory
in their approach. The starting point in this framework they need.
regulatory journey will be different for each

“Leveraging the data governance and the legal system

is essential to enable many digital health transformation
projects, especially the ones addressing identity management,
information access, privacy and data-sharing rights.”

– Conceptual Framework research, Eastern Mediterranean

35
 BOX 3

Advocating for stronger

health data governance
regulation
Transform Health and partners are calling for treaties, from the International Covenant on
a global health data governance framework, Civil and Political Rights and the International
underpinned by equity and rights-based Covenant on Economic, Social and Cultural
principles, to be developed and adopted by Rights to the Convention on the Rights of the
governments through a World Health Assembly Child and the Convention on the Elimination
resolution. It is vital that such a framework of All Forms of Discrimination Against Women,
be developed through a transparent and as well as commitments made in the Universal
inclusive multistakeholder process, including Declaration of Human Rights, the Declaration
the meaningful engagement of civil society on the Future of the Internet and other ICT
and communities. norms and standards.

This would lead to much-needed regulatory It would lay the foundation for improved
standards that countries could adopt into public trust in health data systems, whereby
national legislation to ensure the equitable individuals feel protected, respected and
governance of health data. Such a framework in control of their own data while allowing
should be based on norms and standards that institutions working to protect the health and
draw on duty obligations that countries have well-being of the population to access and use
made to respect, protect and uphold basic it for the public good.
rights, according to the different international

36
 BOX 4

The role of parliamentarians

in digital health
transformation
Over the past decade, parliamentarians, issues. This engagement is also extending
individually or as members of dedicated to digital health care. As one example, the
parliamentary groups and international parliamentary network UNITE* recently created
networks, have become increasingly engaged a dedicated global hub on digital health
in the debate for universal health coverage. and innovation to promote parliamentary
And they have become effective advocates for leadership and strengthen ethical policy
global health issues. Both internationally and ecosystems on innovation for universal health
within their own parliaments, these networks coverage.
have built up coalitions, coordinated advocacy
and shared information in ways that are See www.unitenetwork.org.
increasing the visibility of important health

Comprehensive
plans and strategies
Comprehensive plans and strategies32 are vital guidance for a country as it moves through an
to guide the digital transformation of health inclusive and equitable digital transformation
systems. Governments must be in the driver’s of its health system. Few of these plans are the
seat in their development and delivery while product of broad, multistakeholder engagement
providing the strategic direction that donors and or consultative exercises.
other stakeholders can get behind. Our research
confirmed that many countries have begun At the same time, good practice for such
developing or have some form of strategic strategic plans is beginning to emerge, driven
plans for the digitalisation of their health sector. by the sharing of experience across borders and
However, several plans are already outdated, based on a systematic combination of bottom-
having been rendered obsolete by technological up needs assessments with top-down clarity
developments or the dramatic challenges of purpose and goals.33 Growing expertise is
brought on by the COVID-19 pandemic. The developing – both in countries and in donor
plans differ greatly in detail, feasibility and and advisory organisations that have been
comprehensiveness, and few of them are supporting this work. This expertise, if shared
costed. Although no systematic review has been with and deemed relevant to other countries,
undertaken, an assessment of a sample of these could greatly assist a large number of countries
plans as part of our research indicated that few in their process to digitally transform their health
would qualify as comprehensive or realistic systems.

37
Costing
strategies

Countries’ strategic plans for the digital “Despite the detailed digital
transformation of health systems need to
be realistically and transparently costed.
strategies, it is widely observed
A few countries have costed plans for the and believed by experts that
digital transformation of the health system most countries do not have a
in their country. However, they tend to focus
predominantly on the cost of acquiring and
designated national budget for
deploying digital technology and systems, their digital health programmes.”
rather than on undertaking an inclusive
process that can guide the transformation of - Conceptual Framework research, Asia
the health system. The fact that a digital health
plan often is a subset of a larger national health
plan makes the exercise even more complex.
Where calculations of cost do exist, they are
most often not public and can therefore not
be assessed for feasibility or be the basis for
funding requests by international donors.

38
 “Digital health has not been detected [as] budgeted in national
health strategies and/or plans or in relevant national strategies
and/or plans. There is no information on the estimated
percentage of annual public expenditure on health committed
to digital health.”
– Conceptual Framework research, Latin America

In all regions covered by our research, more for what may be possible with more data and
robust costing data are needed to inform at larger scale. A number of countries have
decisions on the adoption and scaling up of developed national investment road maps,
digital health strategies. In the absence of such such as the Democratic Republic of the Congo
data, there is a lack of information to effectively and the United Republic of Tanzania. Their
plan and budget for the implementation strategy, investment road map and digital
of these strategies. In no region did we find health architecture development processes
evidence of the cost of inclusive processes are emerging as models for other countries. At
and/or the realisation of human rights-based the same time, WHO is building up its capacity
approaches in the digital transformation of as a repository of global goods and national
health being considered. experiences to advise and support countries
undertaking their digital health strategic
This is where comparisons of data between planning process.
countries, good practice and sharing of
experiences are of particular importance. The
cost modelling for this Conceptual Framework
(Chapter 4 and Annex II) provides an orientation

39
Leveraging the full digital
ecosystem, including the
private sector
The private sector has generally been the driver the main challenges. The research from Asia,
of digital technological changes, although for example, featured digital health strategies
in health, as with the initial development of of most countries that already include active
the World Wide Web, the basic research has private sector participation, and the private
often been conducted by universities and sector is consulted in framing policies and
research institutions. As countries progress strategies. However, active collaboration
in their digital maturity, much of the digital between the public and private sectors for
transformation of the health sector is likely to implementation is still at the nascent stage.
be delivered by the private sector, either as
a supplier to public entities of software and It may be necessary to create both a clear
hardware solutions or as a provider of ICT policy environment for what a country
infrastructure and services. Where there are expects from the private sector and what it
viable markets or incentives to create such wants to encourage. It may also be necessary
markets, the private sector is also a crucial to develop an incentive structure to ensure
source of innovation and new solutions. that relevant and important innovations can
benefit populations in the low- and middle-
The private sector is an important provider income countries.
of health care in low- and middle-income
countries, 34 and the research for this report
indicates that the private sector already has
an important role in countries’ digitalisation
of health systems, with coordination as one of

40
Develop digital
competency at every step

From national decision-makers to community Several stakeholders also raised the issue that
health workers, sufficient knowledge and the tasks, requirements and the overall working
training on the management and use of digital reality of the health workforce is changing with
technology is necessary. However, this also the digital transformation of the health system.
needs to be accompanied by an incentive This is a change that needs preparation at all
structure for the workforce that supports the levels, as underlined during the research in the
adoption and use of this digital technology. Eastern Mediterranean.
This, of course, also holds for patients and the
general public who need to understand how “Innovation in digital medicine,
the digital processes work, know how to enter wearables, artificial and augmented
and submit their information and decide how intelligence and telemedicine is
their data will be used, stored and shared. disrupting health care systems and
operating models. Health care decision-
To ensure greater accountability for the
makers must compel health workforces
adoption and use of digital technology, it
to capitalise on this disruption
is critical to outline and support capacity-
by creating and implementing a
strengthening activities across the health
comprehensive digital literacy charter.
sector. It is also important to support academic
institutions and civil society to conduct
Both medical and IT colleges should
research and to advocate for the development embark on this journey of continuous
and implementation of strategic plans and digital learning through knowledge
commitments to ensure digital systems are transfer and benchmarking processes.
being deployed to accelerate universal health They should compare their curricula and
coverage. training programmes against digital
health competency standards and
The findings from the research in all regions are develop a consistent way of measuring
unanimous, that investment in digital literacy performance. It is also imperative to
at every level is crucial for improving service establish certification programmes
delivery and achieving health outcomes. As one in digital health leadership, enterprise
informant in the Latin America and Caribbean
architecture, health data interoperability
region said, “The technology implemented in
and change management.”
the health sector should not be focused on
replacing the competencies of health personnel
– Conceptual Framework research, Eastern
but rather, the objective should be to increase
Mediterranean
or complement human capabilities.”

41
IDENTIFYING AND COSTING
PRIORITY DIGITAL HEALTH
INVESTMENTS

04
This Conceptual Framework includes a The analysis conducted includes five-year cost
modelling analysis to estimate the cost of estimates for the nine-priority digital health
nine priority digital health investment areas investment areas in the low- and lower-middle-
(Table 1) for 78 low- and lower-middle-income income countries.39 It drew on 14 primary data
countries.35 This analysis suggests an estimated sources from the literature and programmatic
investment of US$ 12.5 billion is needed to data review of costed data sources in nine
support the digital transformation of health countries in sub-Saharan Africa and Asia
systems in these countries over the next five (Democratic Republic of the Congo, Ethiopia,
years. This translates to an average of US$ 2.5 Malawi, Mozambique, Nepal, Senegal, United
billion a year, or US$ 0.60 per person per year36. Republic of Tanzania, Zambia and Zanzibar).
It represents approximately 1% of the annual This included national digital health investment
health spending of these same countries.37 road maps, globally available costing resources,
programme data and published literature
This modelling analysis focuses on nine priority (Annex II).
investment areas that were selected based on
input from more than 350 global stakeholders38
who responded to a survey as part of the
research for this Conceptual Framework (annex
II). The estimated investment of US$ 12.5 billion
is based on a medium cost scenario (with the
low case at US$ 7.1 billion and the high case at
US$ 20.5 billion). These results are presented in
Table 2 by priority investment area.

43
 Table 1 Prioritisation of the nine investment areas

Category Area* Abbreviated area definition

Digital connectivity The backbone infrastructure, hardware
infrastructure (connecting and services required for reliable internet
1. Digital connectivity
every health worker and access are available, accessible and
health facility) affordable for all.
Digital approaches to manage financial
transactions for health system-related
2. Financing and financial
Health financing expenses, such as payments to the health
management
workforce and administrative budget
management.
Digitalised job aids that combine an
3. Health worker individual’s health information with the
management and Decision support health care provider’s knowledge and
support clinical protocols to assist them in making
diagnosis and treatment decisions.
The capability of two or more systems
4. Information systems Data exchange and to communicate and exchange data
and data services interoperability through specified data formats and
communication protocols.
Regulation of the use of digital
technologies and data through adequate
5. Policy, governance and legal frameworks and impact assessments
Data and digital governance
research that seek to identify the broader harms
that might be caused by machine learning
and other data-driven tools.
Enterprise architecture,
6. Policy, governance and including governance, The development of guidelines and
research guidelines and standards for standards for interoperability.
interoperability
Digital approaches for monitoring and
7. Supply chain and reporting stock levels, consumption and
Supply chain management
logistics distribution of medicines and medical
commodities.
The delivery of health care services where
8. Service delivery Telemedicine patients and providers are separated by
distance.
A digital system that identifies clients
Client identification and
9. Service delivery and enrols them in patient portals with a
registration
unique user identity.
Note:
*=Prioritised investment areas received the largest number of votes within each category from more than
350 survey respondents who use digital health tools or are digital health experts.

44
The analysis provides an important new maps. Nor does it represent an exhaustive
contribution on the resourcing needs for the list of investments needed for the full digital
digital transformation of the health sector, transformation of health systems. Nevertheless,
given the paucity of costed digital health it provides the first-ever measure of the level
strategies and investment road maps and of investment needed to roll out nine selected
the consequent challenge in accessing data. high-priority digital investments for low- and
It is not, however, a substitute for individual lower-middle-income countries.
country-by-country costed investment road

Table 2 Five-year total cost projections, 2021

Year 1 2 3 4 5

Medium-
5-year breakdown
Investment area 5-year costs Low-cost cost scenario High-cost
(based on the medium
Costs in 2021, US$ millions scenario (most scenario
scenario)
realistic)
Digital connectivity infrastructure
(connecting every health worker 4820 9693 17 001
and health facility)
Telemedicine
(provision of health care services at 819 983 1228
a distance)
Decision support
(digitalised job aids combining
515 618 772
patient health information and
clinical protocols)
Health financing
(digital approaches to manage 400 480 600
financial transactions)
Supply chain management
(digital approaches for monitoring 255 306 382
and reporting stock levels)
Data exchange and
interoperability
139 167 209
(multiple systems communicating
and exchanging data)
Client identification and
registration
118 141 177
(identifying and enrolling clients in
a patient portal)
Enterprise architecture, including
governance, guidelines and 79 95 118
standards for interoperability
Data and digital governance
(regulating the use of digital 17 20 25
technologies and data)

Total 5-year costs, US$ millions 7 162 12 503 20 512

45
As the analysis shows, digital connectivity • Operations costs, which include
infrastructure costs are the highest cost the ongoing costs of maintaining an
intervention and account for more than three intervention, such as replacement
quarters of the total projected cost. These equipment, refresher training, software
costs are limited to the health sector (health licensing, project management and help
record digitisation, wide and local area desk support.
networks within facilities and ICT equipment
needed at facilities) and do not include the The derived costs were extrapolated to other
greater investment required to increase digital low- and lower-middle-income countries.
connectivity and use among the population. “Deployment” costs, subject to certain
Of these infrastructure costs, 40% is for the exceptions, were extrapolated on a per capita
capital equipment that would serve as the basis. “Development” costs do not scale based
foundation on which the other investment on population size. For “operations” costs, in
areas would operate. The corollary of this is the absence of better data, high, medium and
that the cost of adding the other eight priority low ranges were developed in reference to
areas, which would generally benefit from the total system costs over a five-year period.
and build on the infrastructure investment, Operations costs were assumed to continue
is relatively modest in comparison. This in each year of a product’s lifespan. Costings
would likely be the case for the many digital were then adjusted to reflect differences
health areas not making our priority list for in prices across countries by applying
this analysis, but which could be pursued by purchasing power parity (PPP) ratios, and
countries. Although each investment area inflation was accounted for by adjusting all
was costed separately, careful consideration values to be representative of 2021 US dollars.
was given to the benefits of implementing
a suite of solutions (such as cost-sharing of The five-year breakdown of costs (Figure 4)
laptops at facilities) so that duplications are is based on modelled estimates of when the
avoided. expense would occur, in line with the three
phases. Year-five costs represent the ongoing
Costs were assumed in three distinct phases year-on-year operating costs that are needed
of the implementation process: to maintain the investment areas. The annual
• Development costs, which include breakdown of costs for low- and lower-income
software development, the human countries is then shown in Table 3.
resources associated with scoping
and planning implementation and
the development of capacity-building
materials.
• Deployment costs, which include
all costs of scaling up a programme,
including one-time costs for equipment,
software development to address arising
challenges and capacity-building through
new deployment training.

46
 Development, deployment and operations costs, by year
Figure 4
(medium scenario, in US$ millions)

4500

4000

3500

3000

2500

2000

1500

1000

500

0
Year 1 Year 2 Year 3 Year 4 Year 5
(represents ongoing costs)

Develop Deploy Operations

Table 3 Projected costings, by country income classification

Annual investment by country income Years

Year 1 Year 2 Year 3 Year 4 Year 5
classification 2021 US$ millions 1–5

Low-income 102 469 595 720 378 2264

Lower-middle income 274 2184 2752 3322 1706 10 238

Total by year 376 2653 3347 4042 2084 12 502

The overall investment need strongly skews, versus 24) and the highly populated countries
at more than 75%, towards the lower-middle- within the lower-middle-income country
income classification of countries. This is a cohort, which includes Bangladesh, India,
function of the larger number of countries (54 Indonesia, Nigeria and Pakistan.

47
Inherent
limitations of
the analysis
These nine investment areas do not represent
an exhaustive list of the investments needed for
a full digital transformation of health systems.
Nor do they represent the priority investments
that any particular country may choose. Instead,
they represent building blocks that likely will
require complementary investments.

A further limitation of the cost extrapolation

is the availability of cost data. Even where
data exists, there is often a reluctance to share
what might be seen as commercially sensitive
information. The analysis thus relied on costing
information primarily from countries in sub-
Saharan Africa. And the costing data that were
used frequently excluded the operations costs
that are required to maintain the digital health
solution. Scenario analysis was performed
specifically for operating costs based on the
limited available data. The research confirmed
that costing information is scarce even within
countries with developed national digital
health strategies.

48
Observations arising from
the modelling analysis
• While acknowledging the limitations of • Digital health solutions can have a rapid
the modelling analysis, this exercise has deployment and are modelled to occur in
enabled an estimation of the projected cost years two through four of this model, with a
for a set of nine priority investment areas in linear scale each year.
digital health, selected based on the input • Available data suggests that operations
from the global stakeholders. costs, which include ongoing costs for
• The largest cost by far relates to the maintenance, equipment replacement,
investment in infrastructure needs within refresher training, software licensing, project
health facilities, which accounts for around management and help desk support, are
75% of the total projected cost. Of this 40% significant. They make up between 40%
is for the capital equipment that would and 60% of total costs occurring over years
serve as the foundation on which the two through five. These essential costs are
other investment areas would operate. The often not fully accounted for in costing
corollary of this is that the cost of adding analyses.
the other eight priority areas, which would • Year-five costs represent the ongoing year-
generally benefit from and build on the on-year operating costs that are needed to
infrastructure investment, is relatively maintain the investment areas.
modest in comparison. This would also
likely be the case for the many digital The methodology for prioritisation, costing and
health areas not making our priority list for extrapolation of the nine priority investment
this analysis, but which may in reality be areas and the inherent limitations of this
pursued by countries based on their unique analysis are more fully described in Annex II.
choices.
• Development costs, including software
development and human resource
costs related to scoping and planning
implementation, are relatively low as a
proportion of total costs for most investment
areas and are estimated in this analysis to
occur in year one.

49
The report is a milestone for Transform Health, as it will underpin the
coalition’s advocacy efforts in the coming years to call for increased
and coordinated domestic and international financial investments
along the costed nine priority investment areas, to ensure that
digital transformation of health systems is equitable, inclusive and
sustainable.”

Mathilde Forslund
Executive Director of Transform Health

There is a clear need If we truly want to leave no

to develop a more one behind, bridging the
comprehensive approach to digital divide is fundamental.
the digital transformation Now more than ever before,
of health systems and our governments need to
medical care, particularly prioritise funding the digital
in Low-and Lower-Middle- transformation of our health
Income Countries. This is systems. However, if not
why Fondation Botnar is so intentionally centered around
thrilled to work with other community mobilisation
members of Transform Health and ownership, youth
to develop the Conceptual engagement, digital literacy
Framework for Digital and gender equality, any
Transformation. We hope that investments made will only
this important collaboration further deepen the digital
will lead to increased and divide.”
improved investments for
the digital transformation Yacine Ndiaye
of health systems, and to Member of Young Experts: Tech for Health

more equitable access for

generations to come.”

Stefan Germann
CEO of Fondation Botnar

50
THE IMPACT FROM DIGITAL
HEALTH INVESTMENTS

05
If done right, digital health can enable health Notwithstanding the challenges in quantifying
provision to be more nimble, responsive to impact, there is no shortage of case studies
population needs, equitable and effective in (see national and regional impact examples)
all aspects of the care continuum. This can and evidence that illustrate this impact,
deliver healthier populations, cost efficiencies including recently from the global response
and enhanced economic growth. However, to COVID-19 (Box 5). For example, digital
quantitative measurement of the impact of health can improve equity by connecting
digital health interventions – whether health remote, rural and underserved communities
outcomes or financial or economic gains – is with referral centres and expert care; improve
complex. First, digital health interventions are quality of care by training health care providers
typically embedded within and are an integral and with digital solutions for diagnosis, clinical
part of a larger health system. The impact is decision-support systems, supervision or
often a collective outcome of many elements monitoring patient compliance; optimise
of the health system, digital and non-digital. resource allocation and lower health care
Second, the benefits from these interventions costs through more efficient care coordination
are shared by multiple stakeholders, including (with electronic medical records); improve
health care providers and beneficiaries, data management for surveillance, reporting,
making them complicated to quantify and accountability and monitoring; and facilitate
assess. Third, there is a dearth of available communications between health workers,
data, making it difficult to assess the health specialists and patients.40
gains (lives saved, illness averted) or financial
or economic gains directly attributable to a
single digital health investment, let alone the
digital health segment as a whole. Although
several groups are developing frameworks
and methodologies to standardise economic
evaluation and impact measures from digital
health interventions, at present there are few
studies to draw upon.

52
 BOX 5

Digital health in
the times of COVID-19

In 2020, COVID-19 brought the provision of “Rapid innovations in the

health services and digital services into an ever-
closer relationship, as governments, regulators
development and use of digital
and commercial operators scrambled to applications in tracing and
collaborate for the common good in a context combating COVID-19 in most
in which human contact was necessarily
limited. Emergency measures were hasty and
regional countries evidence the
unplanned but delivered valuable lessons. growing digital health maturity in
Digital services and tools had an instrumental the region.”
role in how the world responded to the
pandemic, and they continue to guide the – Conceptual Framework research, Asia
world as it strengthens systems for pandemic
prevention, preparedness and response.

As the International Telecommunication

Union reported, “COVID 19 has been a
uniquely powerful game-changer, with digital
connectivity now at the top of every nation’s
agenda. The crisis has acted as both catalyst,
upending legacy processes and effecting
cultural change, and [as an] accelerator, driving
online trends that may otherwise have taken a
decade to emerge.”41

53
Digital tools have been used extensively in disease cases increase over expected
the response to the COVID-19 pandemic and levels. It is aligned with the Africa-wide
in relation to better pandemic preparedness, Integrated Disease Surveillance and
for example: Response strategy (IDSR). The integration
of infectious disease surveillance with the
• Digital contact tracing systems via management of outbreak response in a
smartphones were rapidly developed to single software platform can strengthen
protect the public (often in collaboration disease control capabilities. Developed
with commercial actors), after manual in Nigeria in 2015, this digital public good
systems began breaking down under has been introduced at the national
caseload levels. For example, the Arogya level in Nigeria and Ghana. In at least 10
Setu, a mobile application launched in other countries in sub-Saharan Africa,
April 2021 by the Government of India Europe, Asia and the Pacific as well
for self-assessment, contact tracing and as in two subregions in sub-Saharan
syndromic mapping of COVID-19, soon Africa, SORMAS is being used or recently
became the most downloaded health introduced.43
care application in the world, with nearly
218 million downloads as of 27 August The pandemic has highlighted how health
2022.42 (human, animal and environmental) can
• Vaccine certification was introduced using be served by digital solutions. But it has
digital IDs, smartphones and ICT access raised issues of equality, public trust and the
to government services, all of which were interconnectedness of health benefits with
made accessible by changes to the cost other public goods. While services improved
and governance of ICT infrastructure by for those who already had internet access,
national, regional and commercial actors. the International Telecommunication Union
• The Surveillance, Outbreak Response noted that “those without service in a world
Management and Analysis System functioning increasingly online were literally
(SORMAS), a process management and figuratively disconnected.”44
tool, uses algorithms to generate early
warnings of potential outbreaks when

54
Health impact from two
priority intervention areas
As part of this Conceptual Framework, analysis investment areas: supply chain management
was conducted to estimate the potential health and decision-support tools (Box 6; see also
impact from digital health investment in terms Annex III for more detail).
of lives saved, focusing on two of the priority

BOX 6

Lives saved case studies for

two priority investment areas

Digitalised supply chain 10% reduction in stockoutsc of vaccines during

management the five years 2023 to 2027. And nearly 1 mil-
lion lives could be saved through a similar re-
In many low- and lower-middle-income coun- duction in stockouts of non-vaccine medicines
tries, paper-based systems requiring manual across all countries (Table A)d. Three scenarios
data entry are common at the most periph- were run in the model based on the reduction
eral levels of the health system. Digitalised in stockout data.
last-mile supply chain management systems
can improve the supply and distribution of A PATH and Digital Square literature review
health commodities by automating the differ- identified a 5–14 percentage point reduction
ent steps, thus reducing stockouts, waste and in stockouts with digitalised last-mile supply
supply chain inefficiencies.a Based on a Lives chain management. The modelling was
Saved Tool (LiST) analysis,b we estimated that based on stockout rates of 5% (Low case), 10%
more than 348 000 lives could be saved in low- (Medium) and 15% (High)e.
and lower-middle-income countries with a

55
 Table A Child lives saved by digitalised supply chain management scenario, 2023-2027

Low Medium High

5% stockout 10% stockout 15% stockout
reduction reduction reduction

Vaccines* 214 658 348 149 456 283

Non-vaccines medicines** 495 746 961 499 1 483 358

Note:
*=Vaccines refer to Bacillus Calmette-Guerin (BCG), diphtheria-pertussis-tetanus (DPT), haemophilus influenza type B (HiB),
hepatitis B, measles, pneumococcal, polio, rotavirus and tetanus toxoid. ** Non-vaccines refer to antibiotics for premature
or prolonged rupture of membrane, antibiotics for dysentery, injectable antibiotics, oral antibiotics for pneumonia, oral
rehydration salts, syphilis detection and treatment, vitamin A for treatment of measles, zinc treatment for diarrhoea.

Decision-support tools that can be saved was estimated. Sensitivity

analysis was performed to highlight ranges
The health impact of electronic clinical in the data for select inputs. For this analysis,
decision-support tools that combine an we assumed that a decision-support tool will
individual’s health information with a health enable a health care provider to fully adhere
care provider’s knowledge and clinical to the IMCI guidelines, thus reducing the case
protocols was estimated for children younger fatality rate by 13%i.
than 5 years suffering from pneumonia.
WHO and UNICEF created a strategy for the Based on this analysis, implementing electronic
integrated management of childhood illness clinical decision-support tools could reduce
(IMCI)f that provides health care workers with childhood pneumonia mortality by around
evidence-based algorithms using history, signs 55 000 (most likely scenario) by improving
and symptoms to determine the best course adherence to the IMCI guidelines. More than
of management. The decision-support tools 40% of these lives saved occurred in the fifth
have potential for enhanced management of year, once reaching full scale – suggesting that
childhood illnesses in primary care settingsg. over a five-year period – following scale up –
around 110 000 lives could be saved. While this
The potential impact in terms of lives saved modelling exercise focused on pneumonia in
among children younger than 5 years in low- children younger than 5 years, the decision-
and lower-middle-income countries was support tool could also have impact on
modelled by multiplying average pneumonia other disease areas (fever, cough, breathing
incidence across these countries to estimate problems, diarrhoea, vomiting and other
the number of children with pneumoniah. symptoms in primary health care settings) and
By applying case fatality rates of pneumonia patient age groups, depending on the scope
with or without an electronic clinical decision- of the clinical algorithm.
support tool, the potential number of lives

56
 Table
TABLE B B Child lives saved by eCDST scenario, 2023-2027

Low Medium High

Electronic decision-support tool 19 559 54 255 125 949

Notes:
a = Bjørn-Ingar Bergum, Petter Nielsen and Johan Ivar Sæbø, “Patchworks of Logistics Management Information Systems:
Challenges or Solutions for Developing Countries?” IFIP Advances in Information and Communication Technology, 504.
Springer, Cham. (2017): 47–58. https://doi.org/10.1007/978-3-319-59111-7_5.

b = The Lives Saved Tool (LiST), developed by the Johns Hopkins Bloomberg School of Public Health, was used for this analysis.
The model quantifies the potential number of lives saved of children younger than 5 years with changes in intervention
coverage rates.

c = Stockouts are commonly defined as a commodity that is expected to be available at a health facility but that has zero
reported stock at any point during a defined period.

d = This analysis extended a study previously conducted by PATH and Digital Square, which estimated the lives saved in
children younger than 5 years in three countries using the LiST, to the remaining low- and lower-middle income countries.
The literature review conducted by PATH and Digital Square identified a 5–14 percentage point reduction in stockouts
through implementing a digitalised last-mile supply chain management. Five years of impact were modelled between 2023
and 2027 to match the costing analysis. This analysis should be interpreted with caution, given the stockout rate reduction
data was derived from a small number of studies. Furthermore, there are many factors that influence coverage of vaccines
and essential medicines beyond stockout levels, including ability to pay, having a qualified workforce, trust in the health
system and infrastructure to support the supply chain.

e = This analysis extended a study previously conducted by PATH and Digital Square, which estimated the lives saved among
children younger than 5 years in three countries using the LiST, to the remaining low- and lower-middle income countries.

f = World Health Organization, “Integrated Management of Childhood Illness,” www.who.int/teams/maternal-newborn-child-

adolescent-health-and-ageing/child-health/integrated-management-of-childhood-illness.

g = Kristina Keitel and Valérie D’Acremont, “Electronic Clinical Decision Algorithms for the Integrated Primary Care
Management of Febrile Children in Low-resource Settings: Review of Existing Tools,” Clinical Microbiology and Infection 24
no. 8 (2018): 845–855, https://doi.org/10.1016/j.cmi.2018.04.014.

h = The modelling used the scenario analysis to highlight different uptake curves for the clinical decision-support tool and
different levels for links to the appropriate diagnostics and treatments. Adaptations to the IMCI guidelines may be needed,
depending on the epidemiological profile of a country, availability of medicines and commodities and other factors. Health
care providers will need to learn how to use the electronic clinical decision-support tools and may need to receive refresher
IMCI training. Even if a decision-support tool is in place, it is also important to consider whether there are links to quality care,
such as access to appropriate diagnostics and medicines. The ranges in the model inputs, such as the case fatality rate of
pneumonia in children, the coverage uptake of the intervention and the link to care, highlight limitations in this analysis. The
data on a support tool improving patient care decisions are still limited, and the results need to be interpreted with caution.

i = Tarun Gera et al., “Integrated Management of Childhood Illness (IMCI) Strategy for Children Under Five,” Cochrane Database
of Systematic Reviews 6. no. CD010123 (2016), https://doi.org/10.1002/14651858.CD010123.pub2.

57
Examples of national
and regional impact
There are many examples of how digital health is making a real, though not always quantifiable,
impact on health services.

In Malawi, a broad partnership of public and private bodies45 is piloting a smart register
based on Digital Square’s global good OpenSRP in a rural area without reliable energy. Us-
er-friendly handheld tablets powered by solar panels and batteries ensure that the local
health staff have access to decision-making support and digital recordkeeping tools, based
on WHO standards to guide diagnosis and treatment. Registration of women and children
in maternity clinics also captures data used for future postnatal, vaccination and child health
programmes.46

Zipline, a logistics innovator known for Through a dedicated Data Science Cata-
drone delivery of medicines and other lytic Fund of currently US$ 25 million, the
medical supplies to health programmes Global Fund invests in the introduction
and patients in remote areas, started in and strengthening of digital solutions to
2016 as a public–private partnership with improve the collection and use of commu-
the Government of Rwanda. “This part- nity health data in Burkina Faso, Ethiopia,
nership focused entirely on benefit ver- Rwanda and Uganda. First results include
sus risk to iterate through test phases, to combining previously siloed COVID-19
share data that would support next steps data systems in Rwanda and developing
and to cultivate an unparalleled culture of e-learning materials for health extension
safety now attempting to be mirrored the workers in Ethiopia. The Global Fund has
world over.” In 2019, the Government of attracted leading private sector partners to
Ghana integrated Zipline’s services into its join the Tech Collective, which was found-
supply chain with support from Gavi, the ed to support the aims of the Data Science
UPS Foundation, the Bill & Melinda Gates Catalytic Fund. Moving forward, the Data
Foundation and other partners. Today, the Science Catalytic Fund aims to “accelerate
level of ambition is at national scale, “In- the way countries supported by the Global
creasingly, Zipline is focused on partnering Fund allocate resources in future funding
directly with national governments. The cycles to support digitalisation and data
company sees this approach as key to go- use for community health”.47
ing to scale.”48

58
Leap, an m-Learning platform for training community health workers in Kenya, is the out-
come of a partnership between the NGO Amref Health Africa, the Government, the M-Pesa
Foundation and three private sector companies – Accenture Development Partnerships, Sa-
faricom Ltd and Vodafone (Mezzanine). Each has a unique role and offerings, from financial
and managerial to cultural and technical. Amref was responsible for Leap’s vision and stra-
tegic direction and provided day-to-day project leadership and community engagement.49
The outcomes of the platform include 60 000 community health volunteers being trained on
COVID-19 across Kenya in 2021,50 and the platform is being adopted in Ethiopia as part of the
Government’s COVID-19 response.51

CarePay was founded through a collab- In India, three electronic medical record
oration of Safaricom and PharmAccess systems have been successfully scaled up
Foundation and established as a social en- to support health service provision. eHos-
terprise through blended finance. CarePay pital, launched in 2017, provides a nation-
developed a smart health exchange plat- al health management system with elec-
form branded as M-TIBA (in Kenya). M-TI- tronic medical record functionality in the
BA streamlines the management of large- public sector and has been adopted by
scale health financing schemes, including many states. ANMOL, launched in 2016,
enrolment, payments scheme administra- is a mobile electronic medical record sys-
tion and data management. M-TIBA is ac- tem that supports nearly 300 000 auxiliary
celerating the transformation of the health nurse midwives. PM-JAY, rolled out in 2018,
care market in sub-Saharan Africa by cre- connects patients and health workers with
ating new digital solidarity mechanisms, the national health insurance scheme and
whereby people pay for each other, which processes 50–60% of India’s health trans-
demonstrates how funding can be chan- actions across the public and private sec-
nelled to target groups at low transaction tors. In all cases, robust domestic govern-
costs. Since its launch in 2016, the cloud- ment financing, strong ICT capacity and
based platform has connected more than local vendor engagement, including the
4.7 million people to M-TIBA and to more private sector, were critical for enabling
than 3 700 health care providers.52 the scaling up and the sustainability.53

In Lebanon, the Ministry of Health started an initiative in 2017 to provide remote primary
care coverage to refugee camps. The project successfully integrated telehealth services in
30 primary health centres across 26 districts, with three main hubs (the American University
of Beirut, Hotel Dieu de France and St. Georges Hospital University Medical Center). The
implementation plan and solution design of this project included the provision of a cybersecure
medical tablet, with the ability to conduct a secure video conference and a full range of vital
sign measurements. For instance, the system can measure cardiopulmonary data, SPO2
Pulse oximetry and non-invasive blood pressure through its electronic stethoscope.54

59
There is increasing evidence of the beneficial
impacts – health and financial – that can flow
from digital health-enabled health systems.
These benefits, which flow to multiple
stakeholders, are difficult to quantify on a
whole-of-digital health basis. But based on
analysis available and anecdotal and other
evidence gathered from the regions for this
Conceptual Framework, the potential for
impact is clear. This underscores why the
appropriate, planned and balanced application
of digital technologies should be central to
the global efforts to achieve universal health
coverage by 2030.

“Digital transformations have

the potential to bring both
enormous long-term benefits
and substantial disruption in
many different areas of health
and health care – in fact, the
effect of digital transformations
has been so pervasive that it
might soon become a dominant
prism through which we can
understand and address health
and well-being dynamics.”

– Governing Health Futures 2030 Commission,

2021

60
A CALL FOR INCREASED,
BETTER COORDINATED
AND ALIGNED INVESTMENT

06
The projected funding of US$ 2.5 billion The resource needs presented here do not
a year (on average) for the next five years appear prohibitive. We contend that much
provides a gauge of the collective investment of this need, in the order of 60–70%,55 can be
required from all stakeholders to support covered by domestic funding. The remaining
important aspects of next phase of the digital gap, which we estimate to be in the range of US$
transformation of health systems in low- and 1 billion per year, can conceivably be covered by
lower-middle-income countries. multilateral donors and development banks,
existing global funding mechanisms, such as
Countries must take the lead in funding their Gavi, the Global Financing Facility for Women,
own public health system and in attracting Children and Adolescents (GFF), the Global
other resources to cover the gaps. This will Fund, private foundations and bilateral donors.
require collaboration between national
governments, the international donor and Coordination platforms should be strengthened
philanthropic community and the private and expanded to indicate investment
sector, each with pivotal roles. Critically, this pathways. WHO should take a strong role in
requires coordination to avoid the challenge this coordination effort while working with
of fragmentation, which this Conceptual other actors engaging in this space.
Framework highlights as a major concern. It
also requires an engaged civil society to create This chapter explores the role of the funding
demand for this funding and to hold decision stakeholders – domestic and international –
makers to account. in contributing more and better coordinated
financing to accelerate the pace of the digital
The need to increase coordinated and transformation of health systems so that low-
aligned international investments in the and lower-middle-income countries can reap
digital transformation of health is particularly the benefits that digital health technologies
important for the initial task of developing offer.
strategic plans and in ensuring the legislative,
regulatory and policy environment is updated
and enabling a more equitable, inclusive and
sustainable transformation. Support for this
aspect of the digital transformation agenda is
vital, both through the disbursement of funds,
which signals the importance of this work
to all stakeholders, and by ensuring better
coordination among donors and alignment
with domestic funding.

62
National governments’ critical
role in financing and enabling
digital health investments
Governments have the core responsibility National governments’ share of funding for
to deliver on the right to health of their digital health transformation will vary from
populations. Similarly, they hold the key to country to country, based on national income
the digital transformation of their health level, access to donor and concessional funding
systems. Governments must commit adequate and level of digital maturity. Commitment to
domestic funding to digital health and through digitalisation will also be driven by political
their actions, strategies and policies, have the will. The digital transformation of health
capacity to encourage and enable bilateral, must be an all-of-government endeavour.
multilateral and private sector investment. Health ministries may advocate for funding
They are therefore both investors and enablers but will not necessarily take the lead role in
of greater investment: as part of health system allocating financial resources to the digital
investment and in relation to the broadband transformation of health systems. This is more
infrastructure that supports all digital health likely a responsibility of ministries of finance,
services. information, technology or planning. But these
ministries might, in many countries, have a
significant budget for digital transformation, a
“Few countries have this [legal
proportion of which should be made available
environment] in place, and digital for the health sector.
health is currently a bit of a wild
west.”

– Transform Health Survey respondent

63
If there is no prioritised costing of the digital “The main problem found in the
health investment needs through national
digital health strategies, it is unlikely that
region is that in the absence of a
allocations for such plans will feature in national national digital health strategy, it
budgets. This will undermine the prospects of is extremely difficult for donors to
securing funding from non-health ministries.
As discussed in Chapter 3, a well-articulated
align their investments with these
digital health strategy, enabling legal and strategies.”
regulatory frameworks, a comprehensive
costing, and high-level political leadership – Conceptual Framework research,
and commitment are requisites to attracting Latin America
investment, including from the national
budget. Developing digital health strategies
and an associated investment road map as
an integral part of health and health systems’
strategies should be national government
priorities. However, in many low- and lower-
middle-income countries, there is insufficient
funding and political support to develop these
strategies and road maps. This lack of funding
often leads to national health Ministries not
being able to draw in the latest technical
expertise and advice that would enable them to
optimise their health systems. Many countries
also lack the legislative and policy environment
necessary to guide the development of digital
health strategies. This is where international
donor funding can play a catalytic role.

64
Donor alignment for more
effective digital health
investment
As the modelling indicates, at US$ 2.5 a country’s digital journey and help finance
billion annually for priority investments, the them, while governments remain in the driver’s
investment for a digital transformation of seat. They must also align among themselves
the health system of low- and lower-middle- to avoid duplication, competition and waste.
income countries is of a relatively manageable This must be prioritised to avoid fragmentation,
scale. Of this we have argued that 60–70% is which is sometimes exacerbated by donor
likely to be met from domestic resources. The investment practices.
remaining US$ 1 billion per year that should
be channelled through international donor USAID, one of the largest bilateral donors
funding will be catalytic for areas that are for the digital transformation of health,
difficult for countries to finance, like strategic acknowledges in its digital health investment
planning, research, international expertise on strategy56 that it “must shift away from siloed,
good practice and preparations for legislative programme-specific funding of information
and policy work. It will also be supportive for technology systems and toward co-investing
inclusive processes that engage all relevant in foundational country-managed and -owned
stakeholders (Chapter 3). Complementary digital infrastructure that supports national
international support can also be catalytic health goals”. It also notes the need to invest
in shaping markets for commodities and in enabling components, such as people,
incentivizing other investments, for example, processes and policies.
from the private sector. Often, the availability of
even modest resources from the international The Principles of Donor Alignment for Digital
community provides an enormous incentive Health57 also recognise the need for alignment
for low- and lower-middle-income countries (Box 7). The principles were developed through
to invest scarce national resources and human broad consultation and adopted in 2018, with
capacity in developing and implementing wide endorsement since. These principles call
these plans. on donors to prioritise58 investments in national
plans; to engage in the dialogue around the
International donors – multilateral agencies, costs of operating, maintaining and sustaining
such as the World Bank, regional development digital health systems; and to invest in the
banks, the global health funds, global programs development of digital health strategies that
and bilateral donors – in conjunction with are commensurate with the digital maturity of
national authorities and civil society need to a country.
both identify the crucial missing elements in

65
“This fragmentation [uncoordinated digital health projects]
is also observed on the side of external investors and donors
due to a lack of coordination between them and a lack of
knowledge of the situation in the region.”
– Conceptual Framework research, Latin America

“There are various programmes supported by donors who have

their own indicators. Some of these do not align with national
[health system strengthening] indicators.”

– Conceptual Framework research, Western and Central Africa

“…digital transformation of health systems is funded by donor

partners, including CDC, USAID, PEPFAR, Global Fund, GIZ
and the Gates Foundation among others…. This funding led
to the development of digital health systems with disease-
based modules to facilitate the management and tracking of
various diseases like HIV and AIDS. …. Key informants note that
there are challenges in maintaining and running these donor-
funded systems.…”

– Conceptual Framework research, Eastern and Southern Africa

66
 BOX 7

Principles of donor alignment

for digital health
While adhering to the Principles of Digital At the same time, donors will invest in:
Development* and working through existing
global and regional efforts, donors will: 6. National strategies: The creation and evo-
lution of a country’s national digital health
1. Collaborate: Collaborate to align invest- strategy, policies and regulatory framework.
ments with national digital health strate- Strategies include such components as ar-
gies. chitecture, standards, investment frame-
2. Prioritise national plans: Prioritise invest- works, privacy protection and detailed op-
ments in national plans that incorporate erational and monitoring plans.
“digital global goods” and avoid bespoke 7. Maturity continuums: Systems at a level
systems. appropriate to the country’s progress along
3. Quantify costs: Engage early to determine the digital health maturity continuum.
and quantify long-term costs of operating, 8. Country capacity: Sustainable country ca-
maintaining and supporting digital health pacity for digital health leadership, gover-
systems for sustainable country ownership. nance, implementation, oversight, global
4. Track and measure: Track investments, good adoption and donor coordination.
progress, learnings and successes in digital 9. Global goods: Scalable, sustainable, acces-
health systems in a transparent manner. sible, interoperable and evidence-based
5. Strengthen donor skills: Strengthen donor digital health global goods that meet coun-
technical skills and core capacities, includ- try priorities.
ing awareness of the Principles for Digital 10. Sharing and peer-learning: Diverse stake-
Development. holder information-sharing and peer-learn-
ing networks at country and regional levels
to foster coordination and alignment of im-
plementation activities.

Source: https://digitalprinciples.org.

67
 BOX 8

Catalysing multisectoral
and multistakeholder
coordination
The Asia e-Health Information Network (AeHIN), These convergence workshops seek to deter-
with support from development partners, mine and rectify gaps in digital health plan-
has assisted health ministries in several Asian ning. They focus on four domains: governance;
countries to convene consultations and coordi- architecture; people and programme man-
nation with various national and international agement; and standards and interoperability.
stakeholders to support national digital health Since 2015, Asia e-health Information Network
programmes. These “convergence workshops” has facilitated such workshops in seven coun-
aim to establish a multisector coordination tries (Bhutan, Indonesia, Lao People’s Demo-
mechanism, with the health ministry as the cratic Republic, Myanmar, Nepal, Timor-Leste
lead agency. They are designed to align with and Viet Nam). These workshops have raised
the Principles of Donor Alignment for Digital awareness of the gaps in terms of governance,
Health and typically cover digital health land- architecture, people and programme man-
scaping and gap analysis. They intend to se- agement, standards and interoperability and
cure the involvement and participation of a what different stakeholders can do to remove
great spectrum of stakeholders whose support the gaps and streamline the national digital
is essential for the digital transformation in the transformation in health care. However, the
country, including academia, development workshops have also highlighted the chal-
partners, NGOs, national professional societies lenges in coordination of national and interna-
in health, informatics, digital health, the indus- tional stakeholders, emphasising the need for
try and other decision-makers, like ministries greater alignment within countries and with
of telecommunications, information technol- and among the development partners.
ogy, communications, finance and planning.

68
According to the OECD,59 digitalisation (overall be leveraged to help improve the coordination
and not specific to health) is not an expressed of digital health investment. But it would require
priority for most of its Development Assistance a commitment from these partners as well as
Committee members,60 including the largest stronger accountability around delivery against
financiers of digital development, despite the the Accelerator’s goals and commitments.
fact that many have explicit digital development Other initiatives, such as the European Union’s
strategies for their official development Digital for Development Hub (D4D), the Digital
assistance funding. Each of these strategies Health Centre of Excellence (DICE) and the
adheres to the Principles of Digital Development Digital Impact Alliance (DIAL), also provide
and recognises the interlinkages between opportunities to enhance coordination.
foundational enablers (universal access to the
internet, digital public infrastructure, policy and
“To make programmes sustainable
regulation and digital skills) and the use of digital
technologies for service delivery. Important
and scalable, we need to help
aspects across all strategies are expansion of strengthen the mainstream
internet access and affordability, supporting government health systems. This
whole-of-government and society processes means that we ought to first
and the evidence-based mainstreaming of
align our programme strategies
digitalisation across all sectors. Looking at
health and digital health, the Governing Health
with our respective partner
Futures 2030 Commission found that “the governments to work in service of
strategic backing is less structured, with the US their priorities and goals. Having
Agency for International Development being governments drive the digital
the only development agency having published
health framework and structure
a strategy specifically for digital health in
2020”. However, from our research we learned
would enable transformational
that more development partners and donors impact, as they are the strongest
(bilateral and multilateral) are strengthening institutions in developing
their portfolio and capacity in this area. countries with long-term and
expansive health policies and
The three largest multilateral funders of health –
the World Bank, the Global Fund and Gavi –are
programs.”
all reviewing their investments in digital tools
as part of their programme funding. Both the – Transform Health survey, donor respondent
Global Fund and Gavi are developing specific
digital strategies. Four years after adoption of the Principles of
Donor Alignment for Digital Health, there is
In view of coordination, the Global Action Plan a need to reaffirm commitment to them and
for Healthy Lives and Well-being for All (known develop specific action plans to ensure better
as the SDG 3 Global Action Plan),61 which brings coordinated investments.
together 13 multilateral health, development
and humanitarian agencies to improve
coordination, includes the Data & Digital Health
Accelerator as well as the Sustainable Financing
for Health Accelerator, which could potentially

69
Role of the private
sector as investor

“The private sector will outpace public sector investment, and

the private and public sectors must work together to ensure
high-quality health delivery for all via collaboration, standards,
compliance bodies and private–public sector partnerships.”

– World Bank, quoted in Conceptual Framework research, Asia

Digital health sits at the juncture between two However, in the absence of proper coordination,
large industries: the health sector and the tech- collaboration, oversight and partnership with
nology sector, both of which include a large the public sector, there is a risk of fragmenta-
array of industries. Within the health sector tion, inconsistent standards and interoperabil-
there are companies focusing on insurance, ity challenges. To capitalise on the diverse of-
pharmaceuticals, medical technology, health ferings of the private sector while safeguarding
care providers and device and diagnostic man- the privacy and human rights of their popula-
ufacturers. The tech sector includes hardware, tions, governments must make clear, through
software, cloud, connectivity and a multiplic- legislation and the right governance mecha-
ity of data technology companies. Others are nisms, how the collaboration should work, em-
engaged in supply chain activities, including phasising the public good.
digitalisation of medicine and vaccine delivery
and storage. These diverse private sector en- “The major risks attributed to the
tities have many different roles in the digital fast-emerging private sector are lack
transformation of health. This includes driving of integration and interoperability,
innovation, productivity and scaling up viable too many similar solutions creating a
solutions. Businesses can also contribute their competing market, solutions devel-
expertise and knowledge across a range of ar- oped with a poor understanding of
eas, including logistics, management, business the country’s digital health ecosys-
modelling, knowledge sharing and technical tem and lack of focus on improving
support. the country’s digital health maturity,
especially in areas such as digital in-
frastructure, enterprise architecture
and interoperability.”

– Conceptual Framework research, Asia

70
“To ensure that private sector investment supports sustainable and
equitable digital transformation, aligned with national priorities and
plans and complements domestic financing. It is important to establish
a coordination platform for all stakeholders, including the private sector
and also define a specific strategy targeting the private sector.”

– Conceptual Framework research, Western and Central Africa

Where there is potential for profitability at The Medical Credit Fund is a debt fund
reasonable risk, the private sector needs no dedicated to financing small and medium-
incentives. A participant in a recent Wilton Park sized enterprises in the health sector in Africa,
discussion with private sector, government and with a focus on primary health care providers.
other partners on Private Capital to Achieve It has a blended fund structure from both
Public Health Goals in Africa made the point public and private donors that has generated
not to “be romantic about why the private substantial capital from multiple sources,
sector invests in projects – businesses seek including impact investor foundations and local
to get a return on their investment. If they commercial banks. The Medical Credit Fund
choose to risk capital, they need a minimum has disbursed more than 7800 loans totalling
return”.62 For digital investments in low- and 145 million euros to 2,000 health enterprises
lower-middle-income countries, where private across Ghana, Kenya, Liberia, Nigeria, United
sector technologies and services may be Republic of Tanzania and Uganda.63
desired, the companies might find it too risky
or not sufficiently lucrative to invest. We have Gavi’s pneumococcal Advance Market Com-
seen this dynamic play out for decades with mitment is an example of a mechanism aim-
the pharmaceutical industry, and the parallels ing to reassure companies that a market would
to the digital technology sector are many be forthcoming to encourage them to invest
and illuminating. We have also seen over the in innovations that may otherwise have been
past 20 years that innovative financing for too risky or just not a priority for them, given
health – where public and private finances are a less profitable market. More recently, the
combined in ways that reduce risk or allow for mechanism addressed the COVID-19 vaccine
financial return – is considerably more difficult supply through the COVAX facility is another
to achieve than what is hoped, and few of the example. Such advance market commitments,
many ideas that have been discussed have impact investments or export credits could in
However, some mechanisms have worked some cases also be explored for digital inno-
in specific contexts. To reduce risk, minority vations and investments. But it requires clear
investments by public entities or credit at parameters and success indicators, and it must
concessional rates have been effective, in some ensure the inclusive involvement of different
cases, to de-risk investments and lower the stakeholders so that innovations respond to
cost of credit. the needs of communities and health workers.

71
Promote inclusion through
targeted funding

While there is consensus on the need to include Targeted international funding to civil society,
current and potential end users and groups, including marginalised groups, can, in this phase
especially the most marginalised communities of the digital transformation of health, make a
and health workers, among others, in all stages tremendous difference to support community
of the digital transformation, few resources are mobilisation and engagement. It should involve
currently available to support this at the national support to enhance civil society’s capacity to
and subnational levels. There is also a lack of engage in the digital transformation dialogue,
data on costs for the necessary actions and including to assess and express their support
approaches to include these populations and and funding needs. Community mobilisation,
their representatives. Nor have adequate costings gender equality and human rights interventions
been carried out to assess the funding needs of in the context of HIV, AIDS, tuberculosis and
establishing an effective and enabling legislative malaria can provide guidance to define and
and regulatory environment. The lack of data on cost any relevant programmatic interventions.
the costs of these interventions means that we Public health history and achievements have
did not include the necessary resource needs for routinely shown – most recently in the response
these critical aspects of the digital transformation to COVID-19 – that community engagement
of health systems in the costing analysis carried is critical. Communities that are empowered
out for this Conceptual Framework. Nonetheless, and with the right support can make a unique
inclusion must be prioritised by governments and invaluable contribution to people-centred
and international funders. policies, costing, implementation and oversight.
Of course, an essential step – as underlined by our
“…inclusion is a key factor youth-led research – is to provide marginalised
groups, other civil society stakeholders as well
to address in building the
as young people with a seat at the decision-
business case [for digital health making table.
interventions] … submitted
business cases should inform “Civil society, affected populations
donors on measures taken to and related organisations are
eliminate the risks of exclusion of rarely consulted during digital
these groups due to their lack of strategy development and the
ability to engage with underlying planning process.”
technologies.”
– Conceptual Framework research, Asia
– Conceptual Framework research, Eastern
Mediterranean

72
Improving data on
financing for digital health
transformation
There are knowledge gaps on funding for the and philanthropic funding, more than tripled
wider digital transformation more broadly and between 2015 and 2019, from US$ 2 billion to
digital health specifically. As the OECD report- US$ 6.8 billion. Of this, 62%, was from multilateral
ed,64 there is no specific guidance in the Devel- institutions. Of this funding for digitalisation,
opment Assistance Committee creditor report- only 3% and 4% of multilateral and bilateral
ing system to track finance for digitalisation, let contributions, respectively, were found to relate
alone digital health. to the health sector.65

Targeted international funding to civil society, in- While there are potential approaches to seek
cluding marginalised groups, can, in this phase of relevant financing data – the Development
the digital transformation of health, make a tre- Assistance Committee policy marker, key word
mendous difference to support community mo- searches, machine learning – none are easy or
bilisation and engagement. It should involve sup- rapidly implementable. This places a greater
port to enhance civil society’s capacity to engage burden on national strategies to identify
in the digital transformation dialogue, including and track funding needs and gaps and for
to assess and express their support and funding organisations, such as WHO and the International
needs. Community mobilisation, gender equality Telecommunication Union, to capture and
and human rights interventions in the context of disseminate this information.
HIV, AIDS, tuberculosis and malaria can provide
guidance to define and cost any relevant pro- There is a clear need for better information on
grammatic interventions. Public health history who funds what in digital health, and increased
and achievements have routinely shown – most transparency is important for the better
recently in the response to COVID-19 – that com- alignment of all sources of funding discussed in
munity engagement is critical. Communities this chapter.
that are empowered and with the right support
can make a unique and invaluable contribution Despite all these shortcomings, now is the
to people-centred policies, costing, implemen- time to provide additional investments for the
tation and oversight. Of course, an essential step digital transformation of health systems in low-
– as underlined by our youth-led research – is to and lower-middle-income countries. Priority
provide marginalised groups, other civil society investment areas have been identified and the
stakeholders as well as young people with a seat evidence of the benefits of these investments
at the decision-making table. is compelling. Even countries that have made
considerable efforts in developing high-quality
The promising news, however, albeit based costed strategies would not necessarily know
on imperfect analysis (in view of data where to turn to if they wanted to complement
shortcomings), is that development finance for their domestic funding with international
digitalisation, comprising bilateral, multilateral resources.

73
There is a need for a mechanism to support better The digitalisation of all aspects of life, including
coordination and alignment of international health, will progress relentlessly but the question
funding. A focused dialog between countries is whether this process will lead to better
requiring additional resources, international health, greater inclusion, improved equity and
organisations and potential international funders stopping the growing digital divide. Even modest
is urgently needed. Without it, there is a risk of additional investments during this period have
greater fragmentation, duplication and waste the potential to build stronger and more resilient
and a perpetuation of these widely reported health systems. As part of people’s right to health,
pervasive practices. There is also a need for strong health systems must be able to cope with the
accountability mechanisms to scrutinise funding new and old multiple threats and risks, including
allocations and to hold funders accountable, both the effects of climate change and health
governments at the national level and donors at emergencies, while delivering quality essential
the global level. health care for all.

There is an urgent need in the coming years

to secure more funding for digital health and
to do so in a manner that is better coordinated
and aligned with national plans and priorities.

74
As the digital transformation of healthcare grows as a priority agenda,
it is imperative to address the emerging reality that, if we are to
achieve UHC by 2030, systems thinking and execution entails not only
digitizing healthcare systems through introduction of individual digital
technologies, but also addressing in tandem the broader enablers of
available, affordable and meaningful digital connectivity for health
systems, individuals and communities to be served. This is at once a
technical and political challenge, that demands investments in digital
infrastructure as well as reform of governance processes that are
informed by upholding and protecting human rights. This approach
is critical to the success of transforming health systems in LMICs by
leveraging the promise and potential of digitalization.

Transform Health’s Conceptual Framework is a timely contribution

outlining how this ‘wicked problem’ can be tackled to ensure health for
all in a digital age. The costing of the identified nine investment priorities
for LMICs will be helpful for policymakers, investors and even citizens to
appreciate the scale of effort ahead.”

Nanjira Sambuli
Vice President of Transform Health

This report clearly shows there is only one way forward to create access
to healthcare for all: together. We, as required ecosystem players - public
sector, civil society, healthcare providers, private sector, funders and
others- need to let go of short term gains and point-solutions, and focus
on sustainable, lasting impact in the health system. It takes courageous
leaders to join forces and to drive such collaborative transformation
in complex ecosystems – yet if we team up, if we use each other’s
complementary capabilities, pool investments, and co-design innovative
revenue models, we can build connected digital health systems that
deliver better and affordable healthcare for all, everywhere.”

Dr Jeroen Maas
Director, Access to Care Technology and Partnerships at Philips and member of the Digital
Connected Care Coalition core team

75
RECOMMENDATIONS

07
This Conceptual Framework outlines the The information gathered through this effort
amount, focus and nature of the investment and the analysis of the current landscape are
needed to support the equitable, inclusive and summarised in the following six recommenda-
sustainable digital transformation of health sys- tions.
tems in low- and lower-middle-income coun-
tries. It rounds out the argument with the ways
forward for how that transformation should
happen.

Recommendation 1 – More investment from domestic and

international sources.

Governments and international donors should prioritise funding

to support low- and lower-middle-income countries in digitally
transforming their health system ensuring it is equitable, inclusive,
sustainable and protective of people’s interests, their right to health,
their privacy and their capacity to participate in its governance. Although
we have projected an average funding need of US$ 2.5 billion per year
for the next five years for nine priority digital health investments areas
for these countries, the true investment requirement will ultimately
be determined country by country and based on costed plans. It will
need to be complemented by wider investment to increase digital
connectivity and usage among the population, as well as investments
to address the broader enabling environment.

The necessary actions include: Development partners, including donors:

(i) Development partners and donors must
National governments: (i) Governments must increase investment in activities that will support
make the equitable, inclusive and sustainable an equitable, inclusive and sustainable digital
digital transformation of health systems a transformation of the health systems in low- and
political priority and reflect this in national lower-middle-income countries. (ii) They must
budgets. (ii) Health ministries must prioritise encourage national stakeholders and other
digital health within the national health budget investors to make the catalytic investments into
as part of wider health system strengthening. (iii) the necessary processes.
Ministries of finance, planning and information
and communication technology will already have Civil society: (i) Civil society must advocate
budgets for digital transformation, a proportion with governments, donors and other financing
of which should be made available for the health mechanisms for increased and better coordinated
sector. and better aligned investments. (ii) Civil society
groups must actively engage in budget and
Health administrators: (i) Health ministries other processes and accountability mechanisms
must engage early with relevant government to continue holding governments and donors
institutions and advocate for national funding, accountable to their digital transformation of
beyond the health budgets, with a clear sense health investment commitments.
of resource needs and gaps. (ii) The health
administrators must engage with development
partners and donors to secure support, including
funding.

77
 Recommendation 2 – Better coordinated and aligned
investments.

International donors and the private sector should ensure that their invest-
ments are coordinated and aligned with national priorities. This should in-
£ clude identifying and strengthening systems and processes that improve
the coordination of funding. Without it, there is a risk of fragmentation,
duplication and waste. At national level, there is a need for coordination
among stakeholders and international donors through transparent pro-
cesses and under the leadership of the government. The widely endorsed
Principles for Donor Alignment for Digital Health provide the blueprint for
this coordinated action and should be fully adhered to and monitored.

To enhance transparency and accountability, there is also a need for mul-

tilateral development institutions to introduce tools at national scale that
track and publish data on funding for digital health as part of their wider
health investment. In addition, WHO should fulfil the wide-ranging stra-
tegic, normative and technical role envisioned for the organisation at the
World Health Assembly meeting in 2018. In this capacity, WHO must mon-
itor the needs and flow of funds for the digital health transformation.

The necessary actions include: WHO, OECD, World Bank and others: (i) Multilat-
eral organisations leading in this space must sup-
National government: (i) Each government port a coordination mechanism that bridges the
must establish a coordinating body under senior gap between countries wanting additional exter-
government leadership to guide international nal funding and potential funders. (ii) They must
partners through robust governance processes. systematically collect and share data on financing
This national coordinating body must have the gaps and needs and (iii) track international fund-
mandate and the power to define the purpose, ing, for example, through a code or a marker in the
goals and direction for the digital transformation OECD’s aid reporting system.
of health systems. (ii) Each government must
refer partners to its national strategies or to Civil society: (i) Civil society must advocate for
opportunities to support the development of its a mechanism to support better coordination
digital transformation. and alignment of international funding and
(ii) must hold domestic and international
Development partners, including donors: (i) funders accountable for better coordinated
In designing and implementing digital health investments and for adherence to the Principles
investment strategies, development partners of Donor Alignment for Digital Health and to the
must adopt, adhere to and report on the Principles commitments with the SDG 3 Global Action Plan.
of Donor Alignment for Digital Health and to
commitments with the SDG 3 Global Action Private sector: (i) Private sector must adopt and
Plan. (ii) Development partners must use existing adhere to the Principles of Donor Alignment
platforms in countries to align their support with the for Digital Health and (ii) align their funding to
country-led priorities and goals while proactively national digital health strategies and contribute
steering away from siloed and programme- towards overcoming funding gaps. (iii) Businesses
specific approaches. (iii) Development partners must engage with governments so that their
must be transparent about their investments in innovations are included in the national strategies.
low- and lower-middle-income countries towards
the digital transformation of health systems.

78
 Recommendation 3 – A costed digital health strategy
and investment road map.

Countries must each develop an inclusive digital health strategy

as an integral component of their universal health coverage
and health system-strengthening agenda. The strategies must
be aligned with the country’s digital health maturity levels, and
they must promote interoperable solutions for connectivity,
capital investment, data governance, legislation and regulation,
literacy and workforce. These solutions need to be developed in
an inclusive and participatory manner, with sufficient time for
consultation with different stakeholders, including civil society,
youth, women and marginalised and hard-to-reach communities,
as well as health workers at all levels of the health system. These
strategies need to be costed and accompanied by a prioritised
and sequenced investment road map that lays out the different
sources of funding as well as the gaps.

The necessary actions include: oversight of national digital health strategies

and their costing. (ii) Civil society groups need
National governments: (i) Health ministries to create alliances across civil society and with
should lead the development and regular youth, women and marginalised and hard-to-
updating and monitoring of national digital reach communities as well as with academia
health strategies and their costing in a process within a country and across countries and
that involves all relevant ministries as well regions to enhance everyone’s knowledge on
as health professionals from all levels of the the digital transformation of health. (iii) Civil
health system, civil society, youth, women and society groups must socialise government plans
marginalised and hard-to-reach communities, and commitments and hold governments
the private sector and academia. (ii) For greater to account for ensuring the meaningful
orientation and accountability, health ministries inclusion of all sectors of society in national
must publish these plans and investment road strategic planning processes. (iv) Civil society
maps and regularly and transparently report groups must monitor the implementation of
on progress. government strategies and plans and provide
feedback on progress and impact at the local
Development partners, including donors: (i) level.
WHO, in coordination with other multilateral
and bilateral technical partners, must Private sector: (i) Businesses must engage in
technically support the development of strategy-planning processes, the costing of
national strategies. (ii) Donors must financially activities and the development of investment
support the work to develop national strategies road maps. (ii) The private sector must support
and associated investment road maps while governments by bringing their industry
ensuring that governments remain in the expertise into the strategy-planning processes
driver’s seat while ensuring that governments remain in the
driver’s seat.
Civil society: (i) Civil society must request and
prepare to engage in the development and the

79
 Recommendation 4 – A robust regulatory framework
and policy environment.

National governments must prioritise establishing a legislative

and regulatory framework and the necessary policies to guide
the digital transformation of their health system so that it is
inclusive, equitable and sustainable. This process must be
based on multistakeholder engagement and include the broad
participation of civil society, including youth, women, older
people, people living with disabilities and marginalised and hard-
to-reach communities. This needs to lay the legal foundations in
terms of health data use, privacy, digital literacy and the policies
for what kind of digitalised health system a country needs to
ensure universal health coverage. A transparent public policy
environment increases planning and investment certainty for
international donors and the private sector and clarifies the
incentives and expectations.

The necessary actions include: Development partners, including donors: (i)

The development partners must invest in the
National governments: (i) A designated processes that create a regulatory framework
ministry must lead a multistakeholder process and a conducive policy environment. (ii) The
to create a robust regulatory framework and a development partners must circulate good
policy environment that ensures compliance. practices across countries and contribute to
(ii) Government agencies must publish policies, policy dialogues.
strategies and other frameworks for easy
access. Civil society: (i) Civil society must engage
in political discussions on the digital
Parliamentarians: (i) Policy-makers must transformation of the health system and the
stimulate political debate and initiate necessary regulations and policies. Where
legislative and regulatory review on the use this does not exist yet, they must ask for
of data and digital technologies for health. (ii) meaningful engagement in relevant national
Policy-makers must understand the gaps and and subnational forums. (ii) Civil society groups
challenges and propose new legislation and must actively participate in the demand for
regulations. (ii) Policy-makers must engage and consultation on the development of
with and create forums for health practitioners, legislation, regulation and standards to govern
academia, the private sector and civil society to the digital health transformation. (iii) Civil
bring their experiences and recommendations society groups must monitor compliance with
into the legislative environment to ensure that new legislation and regulations governing the
laws and regulations are based on the most up- digital transformation of the health system.
to-date data and knowledge.

80
 Recommendation 5 – Mechanisms for meaningful
multistakeholder engagement.

For a digital transformation to be effective in improving health

outcomes and accelerating progress towards universal health
coverage, civil society, including young people, women, older
persons, persons with disabilities and marginalised and hard-to-
reach communities, needs to be involved at all levels of planning,
strategy, execution and monitoring of the transformation. Such
participation needs to be supported financially to ensure that
communities across all strata of society are represented and can
hold decision-makers and service providers accountable.

The necessary actions include: and promote the engagement of civil society,
young people, women and marginalised com-
National governments: (i) Government agen- munities in national coordination platforms
cies must set up inclusive processes to plan, and processes.
implement and oversee the digital transforma-
tion. (ii) Government agencies must meaning- Civil society: (i) Civil society must collect and
fully engage and empower civil society, young communicate the lived experience, concerns
people, women and marginalised communi- and recommendations from communities in
ties to participate in the relevant forums and relation to the digital transformation. (ii) Civ-
in all stages of planning, implementation and il society groups must engage politicians at
oversight. all levels, but particularly at the local level, on
the need to use digital technologies to address
Parliamentarians: (i) Policy-makers must only health system weaknesses and challenges and
approve government budgets that include to accelerate universal health coverage. (iii) Civ-
funding for the digital transformation of health il society groups working on digital technology
systems. (ii) Policy-makers must ensure strong and digital rights must amplify their messag-
oversight of the government’s digital health es by fostering exchanges and alliances across
strategy. (iii) Policy-makers must reach out to and between themselves and with young peo-
civil society, young people, women and mar- ple, women and other marginalised communi-
ginalised communities to seek their experience ties.
with and expectation towards the digital trans-
formation of health systems.

Development partners, including donors: (i)

The development partners must support and
empower civil society, young people, women
and marginalised communities in their en-
gagement by dedicating financial resourc-
es. (ii) The development partners must seek

81
 Recommendation 6 – Improved digital connectivity.

There is urgent need for all stakeholders – national,

international, public and private – to prioritise strategic,
targeted and coordinated actions to close the divide in digital
access. This is a prerequisite for equitable access to technology-
enabled health services. This means addressing coverage gaps,
affordability and digital literacy. It requires political will at all
levels and civil society engagement to mobilise policymakers
and to generate public awareness. If ignored, the divide in
connectivity will widen the health equity gap and further
marginalise already disadvantaged populations.

The necessary actions include: Development partners, including donors: (i)

Aligning with country plans and the national
National government: (i) Government agencies digital road map, the development partners
must recognize the importance of digital access by must financially support the efforts to expand
all sectors of the economy and society and commit connectivity in a coordinated manner. (ii)
to equitable access to the internet for all as a Development partners must ask for and offer
primary policy objective. (ii) Government agencies support targeting the needs of rural and
must work towards lowering prices for entry-level marginalised communities specifically.
broadband towards the Broadband Commission
target of 2% of gross national income per capita. Civil society: (i) The representatives of the public’s
(iii) Government agencies must establish the right interests must call on local politicians to prioritise
incentive structures to encourage network build- digital connectivity in their districts, counties
out that ensures equitable coverage, including and regions. They can create a scorecard to track
in less commercial areas and communities. (iv) local politicians’ commitments and action on
Government agencies must take an active role digital connectivity, taking into account local
in defining the design of digital solutions for specificities. (ii) Civil society groups must raise
health systems to ensure that they respond to community awareness of the necessity for digital
the needs of the end users, taking into account connectivity and create greater public demand for
age, language, literacy and physical and mental the expansion of coverage. (iii) Civil society groups
abilities. (v) Government agencies must ensure must build up local-level digital awareness and
that the end users, including health workers and literacy in areas where they have a programmatic
marginalised communities, are meaningfully or membership presence as a means of driving
engaged in the digital transformation processes, demand for coverage
from development to deployment and oversight.
(vi) Until such time as the usage gap is closed, Private sector: (i) Starting from country plans and
government agencies must ensure that digital legislation, the private sector must diminish the
health technologies do not deepen exclusion and persisting gaps in connectivity by offering services
that services are available in an accessible analogue at affordable prices. (ii) The private sector must
format to communities not yet connected. consider investing a share of their profits into
connecting underserved communities.

82
ANNEXES
 ANNEX I

Development of this report

The analysis at the root of this Conceptual Framework was guided by a broad modelling exercise to
estimate the costs for rolling out priority digital health investments across low- and lower-middle-
income countries. This analysis set out to shed light on the quantum of funding that would be
required for the necessary stepping up in digital health investments.

In addition to this quantitative approach, the work builds on specially commissioned regional research,
perspectives from youth and private sector, a global survey and interviews.

In summary, the Conceptual Framework is based on the following approaches:

• a review of recent publications as referenced;
• a deep dive, including case studies, interviews and stakeholder discussions of country needs and
experience conducted in five regional (in Asia; Eastern Mediterranean; Eastern, Southern, West
and Central Africa; and Latin America);
• a report based on the work of a global youth team that led a survey and focus group discussions
with young people;
• a report commissioned from Digital Health Partnerships on a private sector perspective on the
digital transformation of health;
• a modelling exercise to determine indicative costing of the digital transformation in low- and
lower-middle-income countries based on an expert ranking of investment categories; and
• two case studies exemplarily looking at the impact of digital technologies in two priority
investment areas.

The sum of this combined effort is an indicative assessment of the scale of investment needed to
drive a rapid and successful digital transformation of health in low- and middle-income countries
over the coming five years and recommendations for how to prioritise these investments.

84
 ANNEX II

Methodology and assumptions

underlying the identification
and costing of priority digital
health investments

Background and objectives

To strengthen the Conceptual Framework for an investment case in digital health interventions,
this analysis first determined promising investment areas for digital transformation. Then, for the
selected priority investment areas, PATH and Digital Square conducted analysis to develop a cost
estimate of implementation across 78 low- and lower-middle-income countries.66 Due to missing
purchasing power parity (PPP) values, five countries were excluded from the analysis: Democratic
People’s Republic of Korea, Eritrea, South Sudan, Syrian Arab Republic and Yemen. All mentions in
the discussion of low- and lower-middle-income countries exclude these five countries.

Selection of the prioritised investment areas

The selection of the nine prioritised investment areas featured in this report was based on a global
survey, with more than 350 respondents, and confirmed through discussions with subject matter
experts and with Transform Health’s Global Research Consortium, whose members represent an
array of regional and youth partners.67

The investment areas featured in the survey were based on three primary sources:
1. WHO Classifications on Digital Health Interventions68
2. Tanzania Data Use Partnership Investment Roadmap69
3. The Lancet and Financial Times Commission on Governing Health Futures 2030: Growing
Up in a Digital World70

From these sources, more than 40 potential investment areas were singled out and included in
the survey. These investment areas were grouped into seven categories that broadly aligned with
WHO Building Blocks for Health Systems.71 See Table A1 for the categorisation of the investment
areas and the resulting definitions. The survey participants were asked to select their priority
investment areas within each category. This categorised approach was taken to ensure that at
least one investment area from each category was included in the final output because each
category represents an important step in the digital transformation of health systems.

85
The survey was translated into English, Spanish and French. The survey had minor modifications
with youth-appropriate language for youth survey respondents to ensure inclusion of next-
generation voices and ideas. In January 2022, the survey was launched with targeted outreach
through regional and global networks to governments, the private sector, academia, civil society
and to multilateral and international agencies, donors and foundations. More than 350 responses
were received from individuals who are knowledgeable of or had experience working with digital
health solutions. These respondents represented perspectives within the five focus regions: Asia;
Eastern Mediterranean; Eastern and Southern Africa, West and Central Africa; and Latin America.

The survey results were analysed with a count method, whereby each individual selection of the
investment area resulted in a count of one. The totals were then aggregated together to reflect
all respondents and across groups of stakeholder types and geographic location. This analysis
showed high levels of alignment across the different categories of stakeholders and resulted in
the prioritisation of the nine investment areas listed in Table A1. These investment areas were
then vetted by subject experts to ensure they reflected priorities across the regions and different
sectors.

While the top investment areas were broadly aligned across the stakeholder types, with
between 40% and 70% of individual respondents selecting most investment areas, there were
a few notable nuances. For example, client identification and registration received only 35% of
the total votes within service delivery, yet it was highly prioritised by donors and therefore was
added as a second investment area within the service delivery category. While all stakeholder
types prioritised telemedicine interventions, with many providing additional commentary that
the COVID-19 pandemic has shown the need for digitally available services at a distance, youth
stakeholders also mentioned the importance of personal health tracking interventions.

We acknowledge that these nine investment areas, although priorities, do not represent an
exhaustive list of investments needed for a full digital transformation of health systems. Instead,
they represent building blocks that may require complementary country-specific investments
for a full digital transformation. For example, additional investment areas could include building
digital health strategies, community mobilisation and additional tools for health care workers.
Additional localised research is suggested to identify investment areas needed in a specific
geography. This report has a chosen focus on the detailed analysis for costing the nine prioritised
investment areas, given they were valued by diverse stakeholder types across the five regions of
focus. Based on other costing analyses conducted by Digital Square,72 this investment is likely a
sizeable component of the total investment needed and represents upwards of 50% of the total
costs.

86
 Table A1 Prioritisation of the nine investment areas

Category Area* Abbreviated area definition

Digital connectivity The backbone infrastructure, hardware
infrastructure (connecting and services required for reliable internet
1. Digital connectivity
every health worker, health access are available, accessible and
facility) affordable for all.
Digital approaches to manage financial
transactions for health system-related
2. Financing and financial
Health financing expenses, such as payments to the health
management
workforce and administrative budget
management.
Digitalised job aids that combine an
3. Health worker individual’s health information with the
management and Decision support health care provider’s knowledge and
support clinical protocols to assist them in making
diagnosis and treatment decisions.
The capability of two or more systems
4. Information systems Data exchange and to communicate and exchange data
and data services interoperability through specified data formats and
communication protocols.
Digital connectivity The backbone infrastructure, hardware and
infrastructure (connecting services required for reliable internet access
5. Digital connectivity
every health worker, health are available, accessible and affordable for
facility and household) all.
Digital approaches to manage financial
transactions for health system-related
6. Financing and financial
Health financing expenses, such as payments to the health
management
workforce and administrative budget
management.
Digitalised job aids that combine an
individual’s health information with
7. Health worker
the health care provider’s knowledge
management and Decision support
and clinical protocols to assist health
support
care providers in making diagnosis and
treatment decisions.
The capability of two or more systems
8. Information systems Data exchange and to communicate and exchange data
and data services interoperability through specified data formats and
communication protocols.
Digital connectivity The backbone infrastructure, hardware
infrastructure (connecting and services required for reliable internet
9. Digital connectivity
every health worker, health access are available, accessible and
facility and household) affordable for all.
Note:
*=Prioritised investment areas received the largest number of votes within each category from more than
350 survey respondents who use digital health tools or are digital health experts.

87
Investment area limitations

Survey design limitations: The survey for prioritisation of investment areas included 54 unique
investments, grouped into seven categories. They were not exhaustive of all investment areas and
were included due to their prominence in the three sources provided.73 In addition to the categorised
investment areas, there was a write-in option for additional areas not included in the survey. For
example, community mobilisation and the use of artificial intelligence were mentioned by survey
respondents as high priorities. However, no unprompted write-in investment areas achieved enough
votes to be featured as a high priority. This may in part be because respondents were not presented
with these options in the survey.

Recruitment of respondents: Recruitment of the survey respondents was through targeted outreach
from Transform Health’s global and regional partners.74 This snowball sampling method resulted in
the more than 350 respondents and is indicative of the overall interest and trends. Further localised
research should be conducted to assess the specific needs in each region.

Costing methods

The costing analysis looked to estimate the total cost of implementing the nine priority investment
areas across all low- and lower-middle-income countries. To align with the length of typical national
budget planning cycles, the costing analysis developed five-year cost projections for each investment
area. The analysis began with a targeted literature and programmatic data review that led to costing
data sources for the nine priority investment areas. This targeted review resulted in 14 primary data
sources from nine geographies in sub-Saharan Africa and Asia (Democratic Republic of the Congo,
Ethiopia, Malawi, Mozambique, Nepal, Senegal, United Republic of Tanzania, Zambia and Zanzibar) in
the form of national road maps, globally available costing resources, programme data and published
literature. The cost data within these sources was extracted into a central repository, resulting in more
than 350 cost data line items across all investment areas (see examples in the next paragraph). The
costing methodology then took a six-step approach to extrapolation and scenario development.

Coding cost data: Each unique line item was classified as development, deployment or operations
costs. In circumstances in which there was not a clean division between the categories, costs
containing similar items were grouped together in a similar method.
• Development costs include software development and the human resources associated with
scoping and planning implementation.
• Deployment costs include all costs of scaling up a programme, including one-time costs for
equipment, further software development – as needed – to connect the digital tool within the
local ecosystem and address any new glitches or bugs in the software and then build up capacity
through new deployment training.
• Operations costs include the ongoing costs of maintaining an intervention, including such items
as replacement equipment, refresher training, software licensing, project management and help
desk support.

88
While each investment area was costed separately, careful consideration was given to the benefits of
implementing a suite of solutions. For example, cost-sharing of capital equipment, such as laptops
at facilities, was considered and included as a line item within the digital connectivity infrastructure
investment area. Other individual investment line items were modified to avoid duplication of
these costs. For digital connectivity infrastructure, which has benefits beyond the health sector, a
methodology was generated to only estimate costs for the health sector contribution. More specifically,
infrastructure costs were limited to the digitisation of health records, wide and local area networks
(WAN and LAN) within facilities and the physical information and communication technologies (ICT)
equipment within facilities. The cost of establishing the national systems, such as national broadband
or mobile data coverage, that would be required for these networks to connect into was not included
in the analysis because they are often covered by different actors.

Scaling up the data to additional geographies: Triangulating among the most robust data
sources, these costs were then extrapolated to other low- and lower-middle-income countries. It is
important to stress that for most of the investment areas, the robust data sources came from global
goods products. The donor-funded development and open-source nature of these products make
them well-suited to low digital health maturity markets. Global goods also are more likely to have
product features that are desired by end users in low digital health maturity markets, such as offline
functionality and data compression.75

Development costs are considered fixed costs and held consistent across all geographies. It is possible
that there may be cost efficiencies for leveraging digital health solutions that are developed in another
country, especially global goods, but these efficiencies were not accounted for in this analysis.
Deployment costs, for most investment areas, were scaled up linearly at a per-person level. A per-
person extrapolation was used due to the limited availability of health facility data for the 78 focus
countries. For data governance, enterprise architecture and data exchange and interoperability, costs
were not scaled up based on a country’s population size. These three investment areas were targeted
at national-level stakeholders rather than direct engagement with health providers and patients.
Therefore, the costs for each of these areas was assumed to be the same across all countries.

Operations cost data were not available for most of the investment areas. Therefore, high-, medium-
and low-cost operations scenarios were developed to account for the ongoing costs needed to
maintain digital interventions. These scenarios were built with the evidence from PATH and Digital
Square’s work on supply chain management76 and have been validated as reasonable based on
external resources77 and subject matter experts. The high operations cost scenario allocates 60% of
the total cost over five years to the ongoing operations. In other words, over the course of five years,
40% of the total cost will be spent during the development and the deployment of the investment
area, while 60% of the total cost will be spent on operations costs. Similarly, the medium operations
scenario cost allocates 50% of the total costs and the low operations cost scenario allocates 40%, of
the total cost over five years to the ongoing operations. In all scenarios, it was assumed that these
operations costs would continue in each year of a product’s lifespan.

89
Adjusting for different purchasing power: Each costed line item was then adjusted to reflect
differences in purchasing power across countries. To do so, PPP ratios were developed, comparing
the source PPP to the extrapolated country PPP. Although the source data costed each investment
area in US dollars, the PPP adjustment acknowledges the difference in the purchasing power of a
currency for a set basket of goods and services between countries.

Adjusting for inflation: The data sources used were selected through a targeted literature and data
review and included national road maps, globally available costing resources and programme data.
These sources were developed between 2016 and 2021. While costed in US dollars, the source values
were adjusted to account for annual inflation rates. The resulting figures represent total cost in 2021
US dollars.

Scenario analysis to highlight uncertainty: Different scenarios were developed to reflect the ranges
in observed data. For digital connectivity infrastructure, a range was developed based on the varying
costs in the data sources. There are many reasons infrastructure costs may vary across geographies,
including a given country’s digital health maturity level,78 topography, population density and other
factors. For the eight other investment areas, we developed ranges based on the potential range in
operating costs. These operation cost scenarios created ranges that assume a consistent spread of 40–
60% of the total investment area that could be spent on maintaining functionality of the investments
after implementing.

Distributing costs over five years: To reflect patterns of spend down of the total cost, a five-year
distribution was modelled. This distribution assumes that for all investment areas, all development
costs would be spent in year one. For years two, three and four, a linear deployment of the investment
area would take place and therefore one third of the total capital equipment, deployment and
operations costs would be spent in each year. Year five assumes that the intervention has reached
100% deployment and annual operation costs are the only remaining costs. With this methodology,
it can be assumed that the costs in year five would be recurring in perpetuity, such as in year six and
beyond.

Costing assumptions

Capital equipment: Digital health interventions rely on the availability of capital equipment to operate
effectively. To account for the benefit of implementing a suite of solutions, this analysis assumed that
there is capital equipment-sharing across the priority investment areas. It further assumed that the
nationally costed infrastructure investment area contains sufficient levels of capital equipment for the
functioning of the entire suite of priority investment areas. Therefore, capital equipment expenditures
were removed from all other priority investments.

National-level stakeholder engagement: Data governance, enterprise architecture and data

exchange and interoperability investment areas were considered to have fixed costs due to their
national-level stakeholder engagement and deployment.

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Costing limitations

Data limitations

Geographic representation of data sources: This analysis was conducted with data from nine
geographies in sub-Saharan Africa and Asia: Democratic Republic of the Congo, Ethiopia, Malawi,
Mozambique, Nepal, Senegal, United Republic of Tanzania, Zambia and Zanzibar. Most of the cost
data comes from countries in sub-Saharan Africa and were extrapolated to low- and lower-middle
income countries globally.

Availability of operations costs: There was limited availability of cost data for operations of the priority
investment areas. The team developed three scenarios to account for the total cost of implementing
these solutions.

Availability of PPP values: To account for the localised cost of goods, the team leveraged the World
Bank’s 2020 World Development Indicator “Price level ratio of PPP conversion factor to market
exchange” to adjust for purchasing power between geographies, as discussed previously. The
following five low- and lower-middle income countries lack PPP values and therefore were excluded
from the costing analysis: Democratic People’s Republic of Korea, Eritrea, South Sudan, Syrian Arab
Republic and Yemen.

Methodology limitations

Categorisation of investment area line items: The analytics reviewed each unique line item
within the available data sources to classify the cost as development, deployment or operations.
In circumstances in which there was not a clean division between the categories, costs containing
similar items were grouped together in a similar method for extrapolation purposes.

Population-based scaling of costs between countries: For investment areas that are deployed at
subnational levels, the deployment and operations costs were scaled on a per person basis. While the
team acknowledges these investments would predominantly be deployed at health facilities, a lack
of health facility count data across the majority of low- and lower-middle income countries prevented
meaningful extrapolation to the health facility level and therefore population was used as a substitute
to represent scale.

PPP application: PPP was used to account for differences in costs across the countries. PPP values
were applied to all costs, including capital equipment and labour, but typically they were used only for
tradable goods. There is limited publicly available data on labour costs across low- and lower-middle-
income countries. Although anecdotally there is evidence that technology costs do not always
follow PPP ratios in terms of cost adjustments due to differential pricing schemes by multinational
companies, no data have been found to indicate the differences in cost from scaling technology
when compared to PPP.

91
Digital connectivity infrastructure: For digital connectivity infrastructure, the range was developed
based on varying costs in data sources. There are many reasons infrastructure costs may vary across
geographies including a given country’s digital health maturity level,79 topography, population density
and other factors. These factors were not directly addressed or adjusted for in the range provided.
Further, the costing analysis assumed that the network connectivity (mobile data or broadband) that
a health facility would connect into are in existence or would be funded by entities outside of the
health sector.

Exclusivity: Globally recognized classifications of digital interventions may not be mutually exclusive
from a costing perspective making data interpretation potentially challenging.

Potential for cost savings: This analysis focused on estimating the necessary investment needed
to implement the nine priority investment areas and did not estimate the potential cost savings that
could result from any of the included digital health interventions. Additional research is suggested to
understand the localised potential for cost savings.

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 Year 1 2 3 4 5

Table A2 Five-year total cost projections in 2021

Medium-
5-year breakdown
Investment area 5-year costs Low-cost cost scenario High-cost
(based on the
Costs in 2021, US$ millions scenario (most scenario
medium scenario)
realistic)
Digital connectivity infrastructure
(connecting every health worker and 4820 9693 17 001
health facility)
Telemedicine
(provision of health care services at a 819 983 1228
distance)
Decision support
(digitalised job aids combining patient 515 618 772
health information and clinical protocols)
Health financing
(digital approaches to manage 400 480 600
financial transactions)
Supply chain management
(digital approaches for monitoring and 255 306 382
reporting stock levels)
Data exchange and interoperability
(multiple systems communicating and 139 167 209
exchanging data)
Client identification and registration
(identifying and enrolling clients in a 118 141 177
patient portal)
Enterprise architecture, including
governance, guidelines and standards 79 95 118
for interoperability
Data and digital governance
(regulating the use of digital 17 20 25
technologies and data)

Total 5-year costs, US$ millions 7 162 12 503 20 512

The total five-year cost projections are US$ 7.2 billion, US$ 12.5 billion and US$ 20.5 billion for the low, medium
and high scenarios, respectively. This represents the anticipated cost of implementing all nine investment
areas across the 78 low- and lower-middle-income countries and includes the development, deployment and
operations of each investment area. In the medium scenario, the overall investment is projected to be US$ 12.5
billion over five years, which translates to US$ 2.5 billion on average annually. The annual distribution scenario
model suggests that at full scale, US$ 2 billion would be needed annually for recurring operations costs in the
medium scenario. The primary driver of costs across the selected nine priority intervention areas is the needed
digital connectivity infrastructure, which accounts for approximately 75% of the total projected costs. Within this
investment area, approximately 40% of the cost is dedicated to capital equipment required within the health
facilities that will form the foundation in which other digital health solutions operate. A second driver of cost is
the operations costs, which across the scenarios account for 40–60% of the total cost over five years. These costs
include ongoing maintenance, equipment replacement, software licensing, help desk support and refresher
training and are essential to maintaining the digital investments. However, these costs are often omitted during
budgeting processes.

93
 ANNEX III

Health impact case studies –

Method and results
Health impact case studies

Aligned with the focus of this Conceptual Framework, PATH and Digital Square conducted an analysis
to estimate the potential health impact in terms of lives saved for two of the Conceptual Framework
investment areas across low- and lower-middle-income countries.80 These case studies show the
health impact of digital supply chain management systems and electronic clinical decision-support
tool investments if implemented within these countries. These investment areas were selected
because of the availability of data.

A growing number of groups are developing frameworks and methodologies to standardise

economic evaluation and impact measures from digital health interventions. But at present, there is
limited quantitative evidence on the potential impact of digital interventions on health outcomes.81
Measuring the value of digital health can be challenging due to many positive and negative
externalities (workforce motivation, data privacy violations), the wide variety of potential outcome
measures (health impact, financial savings), the challenge of attributing change to the digital health
intervention as there are many determinants of health and because many different methods for
measuring the resulting impacts.82 The modelling represents the health impact for each investment
area in isolation, based on the inputs and scenarios provided. We could not quantify the amount
of double counting that may occur between the two investment areas modelled and therefore the
results should not be summed.

Further, the team acknowledges that while this analysis focused on the health impact in terms of
lives saved, there are potential cost savings that could result from any of the included digital health
interventions. This analysis was not undertaken due to the lack of available cost-savings data.

Digitalised supply chain management

The estimated health impact on children younger than 5 years through digitalising last-mile supply
chain management systems with capabilities to monitor and report stock levels, consumption and
distribution of medicines was estimated. In many low- and lower-middle-income countries, paper-
based systems requiring manual data entry of health information are common at the most peripheral
levels of the health system. Digitalised last-mile supply chain management systems can improve
the supply and distribution of health commodities by automating the different steps thus lessening
stockouts, waste and supply chain inefficiencies.83

94
The Lives Saved Tool (LiST) that the Johns Hopkins Bloomberg School of Public Health developed was
used to estimate the potential health impact of implementing a digitalised last-mile supply chain
management system in low- and lower-middle-income countries. The model quantifies the potential
number of lives saved in children younger than 5 years with changes in intervention coverage rates
in low- and lower-middle income countries.84 The tool includes country-level data from a variety of
sources, including peer-reviewed journals, the United Nations Population Division, the Demographic
and Health Surveys Programme and the Multiple Indicator Cluster Surveys.85 The model assumes
that each death is due to a single cause and that each death can only be prevented once.

This analysis extended a study previously conducted by PATH and Digital Square that estimated
the lives saved among children younger than 5 years in three countries, also using the LiST,86 to
the remaining low- and lower-middle income countries. The literature review conducted by PATH
and Digital Square identified a 5–14 percentage point reduction in stockouts from implementing a
digitalised last-mile supply chain management system in low- and lower-middle income countries.
Stockouts are commonly defined as a commodity that is expected to be available at a health facility
but that has zero reported stock at any point during a defined period. Stockout reduction data were
inverted to stock availability and improved coverage for vaccines and essential medicines using a
1:1 conversion factor. Three scenarios were modelled based on the range of stockout reduction data
observed in the literature and five years of impact, between 2023 and 2027, were modelled to match
the costing analysis.

Informant interviews indicated a rapid scaling up of a digitised supply chain management tool and
thus the modelling assumed that the full increase in coverage would be realised in the first year.
Implementing a digitalised last-mile supply chain management system in low- and lower-middle
income countries could reduce child mortality by improving coverage of life-saving commodities.
Three scenarios were run in the model based on the identified reduction in stockout data. In the
medium, and most likely, scenario, more than 348 000 lives could be saved by a 10% reduction in
stockouts for vaccine interventions and more than 961 000 lives could be saved by a 10% reduction in
stockouts for non-vaccine medicines across all countries (Table A3). This analysis should be interpreted
with caution, given that the stockout rate reduction data were derived from a small number of studies.
Furthermore, there are many factors that influence coverage of vaccines and essential medicines
beyond stockout levels, including ability to pay, having a qualified workforce, trust in the health system
and infrastructure to support the supply chain.

Table A3 Child lives saved by digitalised supply chain management scenario, 2023-2027

Low Medium High

5% stockout reduction 10% stockout reduction 15% stockout reduction

Vaccines 214 658 348 149 456 283

Non-vaccines 495 746 961 499 1,483 358

Vaccines: Bacillus Calmette -Guerin (BCG), diphtheria-pertussis-tetanus (DPT), haemophilus influenza type B
(HiB), hepatitis B, measles, pneumococcal, polio, rotavirus and tetanus toxoid. Non-vaccine medicines: antibiotics
for premature or prolonged rupture of membrane, antibiotics for dysentery, injectable antibiotics, oral antibiotics
for pneumonia, oral rehydration salts, syphilis detection and treatment, vitamin A for treatment of measles, zinc
treatment for diarrhoea.

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Decision-support tools

The health impact of electronic clinical decision-support tools that combine an individual’s health
information with a health care providers knowledge and clinical protocols was estimated for children
younger than 5 years suffering from pneumonia. To improve access to quality of care in children in
primary health care settings, WHO and UNICEF created the integrated management of childhood
illness (IMCI) strategy.87 The IMCI provides health care workers with evidence-based algorithms that
use history, signs and symptoms to determine the best course of management. However, there is
low adherence with clinical algorithms featured in traditional paper-based guidelines, including the
IMCI.88 While there are many reasons for low adherence to paper-based guidelines, electronic clinical
decision-support tools are promising tools for the management of childhood illnesses in primary care
settings.89

To estimate the potential impact in terms of lives saved in children younger than 5 years in low-
and lower-middle-income countries, a model was generated in Excel. The modelling was achieved
by summing the population of children younger than 5 years across the selected countries and
multiplying average pneumonia incidence across these countries to estimate the number of
children with pneumonia. The next step was to multiply the average proportion of children with
acute respiratory illness that present at a health facility across these same countries to estimate the
number of children with pneumonia that present at a health facility. A case fatality rate of pneumonia
with or without an electronic clinical decision-support tool was applied for children that present at a
health facility to estimate the potential number of lives that could be saved. Sensitivity analysis was
performed to highlight ranges in the data for select inputs (Table A4). For this analysis, we assumed
that an electronic clinical decision-support tool would enable a health care provider to fully adhere to
IMCI guidelines, thus reducing the case fatality rate by 13%.90

Several factors need to be considered when thinking about the uptake of the electronic clinical
decision-support tools. For example, adaptations to IMCI guidelines may be needed, depending on the
epidemiological profile of the country, availability of medicines and commodities and other factors.
Furthermore, health care providers will need to learn how to use the decision-support tools and may
need to receive refresher IMCI training. Even if a decision support tool is in place, it is also important
to consider whether there are links to quality care, such as access to appropriate diagnostics and
medicines. The modelling used scenario analysis to highlight different uptake curves for the clinical
decision-support tool and different levels for links to the appropriate diagnostics and treatments
(Table A4).

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 Table A4 Key child lives saved model inputs and assumptions by eCDST scenario

Low Medium High

436
Population size of children younger than 5 yearsa 436 million 436 million
million

Incidence of pneumonia in children younger than 5 yearsb 24% 24% 24%

Case-fatality rate of pneumonia in children younger than 5

0.4% .65% 1%
yearsc
Proportion of children with acute respiratory illness who seek
67% 67% 67%
care in a health facilityd
Peak coverage rates for the intervention* 43% 57% 72%

Coverage rates for linkages to care 55% 70% 85%

Percentage reduction in the pneumonia case fatality rate

13% 13% 13%
based on adherence to IMCI** 91
Notes:
*= An s-shape uptake curve was generated for coverage of the electronic decision-support tool. For the medium
scenario this represents 5%, 8%, 20%, 45% and 57% coverage over years 1 through year 5, respectively. **=The percent
reduction in case fatality is based on the broad impact of IMCI rather than the pneumonia specific impact of IMCI.
Source: a= See https://population.un.org/wpp/Download/Standard/Population/
b= David A McAllister et al., “Global, Regional and National Estimates of Pneumonia Morbidity and Mortality in
Children Younger Than 5 Years Between 2000 and 2015: A Systematic Analysis,” Lancet Glob Health 7, no. 1 E47-E57
(2019), http://dx.doi.org/10.1016/S2214-109X(18)30408-X. Supplement: https://www.thelancet.com/cms/10.1016/S2214-
109X(18)30408-X/attachment/41ca9e56-e528-4788-bb38-1d4c9f76e6d4/mmc1.pdf.
c= McAllister et al., “Global, Regional and National Estimates of Pneumonia Morbidity and Mortality in Children
Younger Than 5 Years Between 2000 and 2015”; Jessica Floyd et al., “Evaluating the Impact of Pulse Oximetry
on Childhood Pneumonia Mortality in Resource-poor Settings,” Nature 528, no. 7580 (2015): S53-9, https://doi.
org/10.1038/nature16043;
d= The DHS Program, Demographic and Health Surveys, https://dhsprogram.com/Data.

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Implementing an electronic clinical decision-support tool could reduce childhood pneumonia
mortality by improving adherence to IMCI guidelines. In the medium, or most likely scenario, nearly
55 000 lives could be saved across all low- and lower-middle income countries over the five-year
period (Table A5). More than 40% of these lives saved occur in the fifth year, given the intervention
is estimated to have fully scaled. While this modelling exercise focuses on pneumonia in children
younger than 5 years, the decision-support tool could also have an impact on other disease areas
and patient age groups, depending on the scope of the clinical algorithm. A recent observational
study using a clinical decision-support tool found improvements in the quality of care for children
presenting with fever, cough, breathing problems, diarrhoea, vomiting and other symptoms in
primary health care settings.92

The ranges in the model inputs, such as the case fatality rate of pneumonia in children, the coverage
uptake of the intervention and linkage to care, highlight limitations in this analysis. Scenario analysis
was performed to highlight uncertainty in the available data. In addition, a key assumption of this
analysis is that an electronic clinical decision-support tool would enable health care providers to
adhere to the IMCI guidelines and accurately diagnose and treat pneumonia. The data on electronic
clinical decision support tools improving patient care decisions are still limited and the results need
to be interpreted with caution.

Table A5 Child lives saved by eCDST scenario, 2023-2027

Low Medium High

Electronic decision-support tool 19 559 54 255 125 949

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Endnotes

1 The key focus of this report is on 78 of the 82 countries that at the time of writing fall within the World Bank classification
of “low- and lower-middle income” countries. Due to missing purchasing power parity (PPP) values, five countries considered
Low or lower middle income were excluded from the analysis: Democratic People’s Republic of Korea, Eritrea, South Sudan,
Syrian Arab Republic and Yemen. These 78 countries are included in the modelling of the cost for nine priority investment areas
in the digital transformation. They have a combined population of 4.1 billion people. In some cases, the report refers to figures
and characteristics of all “low- and middle- income” countries. This term includes 54 upper-middle-income as well as the 82 low
and lower middle income countries and therefore has a combined population of 6.6 billion.
2 The analysis drew from a targeted programmatic data review that identified costed data sources for the nine priority
investment areas from 14 primary data sources relating to nine geographies in sub-Saharan Africa and Asia (where all but a
few low- and lower-middle-income countries are situated).
3 This is an illustrative estimate by reference to the proportion of domestic spending to international aid spending in low- and
lower-middle income countries health spending from WHO Global health expenditure data base, and domestic investment
proportions from the Global Fund 7th Replenishment projection of available resources.
4 See General Data Protection Regulation (GDPR) of the European Union, https://eur-lex.europa.eu/eli/reg/2016/679/oj
5 See www.healthdataprinciples.org.
6 See OECD Recommendation on Health Data Governance, www.oecd.org/els/health-systems/health-data-governance.htm.
7 Ilona Kickbusch et al., “The Lancet and Financial Times Commission on Governing Health Futures 2030: Growing Up in a
Digital World,” Lancet 398, no. 10312 (2021): 1727-1776, https://doi.org/10.1016/S0140-6736(21)01824-9.
8 World Health Organization, Seventy-First World Health Assembly, Agenda Item 12.4, Digital Health (Geneva: WHO, 2018),
https://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_R7-en.pdf.
9 World Health Organization, Global Strategy on Digital Health 2020–2025 (Geneva: WHO, 2021), https://apps.who.int/iris/
handle/10665/344249.
10 Ilona Kickbusch et al., “The Lancet and Financial Times Commission on Governing Health Futures 2030: Growing Up in a
Digital World,” Lancet 398, no. 10312 (2021): 1727-1776, https://doi.org/10.1016/S0140-6736(21)01824-9.
11 The reference made to individual societal groups does not claim to be comprehensive. To the contrary, which group requires
dedicated attention and what the engagement should look like depends on the country context and must be defined in an
inclusive process.
12 Young Experts: Tech4Health is a network working to centre youth rights and perspectives at the heart of digital transformation
for universal health coverage, https://yet4h.org.
13 The key focus of this report is on 78 of the 82 countries that at the time of writing fall within the World Bank classification
of “low- and lower-middle income” countries. Due to missing purchasing power parity (PPP) values, five countries considered
Low or lower middle income were excluded from the analysis: Democratic People’s Republic of Korea, Eritrea, South Sudan,
Syrian Arab Republic and Yemen. These 78 countries are included in the modelling of the cost for nine priority investment areas
in the digital transformation. They have a combined population of 4.1 billion people. In some cases, the report refers to figures
and characteristics of all “low- and middle- income” countries. This term includes 54 upper-middle-income as well as the 82 low
and lower middle income countries and therefore has a combined population of 6.6 billion.
14 Digital Square, “Closing the Health Equity Gap,” The Atlantic, 2021, www.theatlantic.com/sponsored/digital-square-2021/
closing-health-equity-gap/3661/.

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15 Global Digital Health Index, 2019, www.digitalhealthindex.org.
16 Digital Square, “Market Analytics: Understanding the Digital Health Marketplace” (2021), https://digitalsquare.org/market-
analytics.
17 Organisation for Economic Co-operation and Development, Development Co-operation Report 2021: Shaping a Just Digital
Transformation (Paris: OECD Publishing, 2021), https://doi.org/10.1787/ce08832f-en.
18 International Telecommunication Union, The Global Connectivity Report 2022 (Geneva: ITU, 2022), http://handle.itu.
int/11.1002/pub/81cd4170-en.
19 DataReportal, “Internet Use in China in 2022”, 2022, https://datareportal.com/reports/digital-2022-china.
20 These are the countries where internet access is lowest, World Economic Forum, August 17, 2020, www.weforum.org/
agenda/2020/08/internet-users-usage-countries-change-demographics.
21 Ministry of ICT, Innovation and Youth Affairs, The Kenya National Digital Master Plan 2022-2032 (Nairobi: Government of
Kenya, 2022), https://cms.icta.go.ke/sites/default/files/2022-04/Kenya%20Digital%20Masterplan%202022-2032%20Online%20
Version.pdf.
22 OECD, Development Co-operation Report 2021, 372-377.
23 UN High-Level Panel on Digital Cooperation, The Age of Digital Interdependence (Geneva: 2019), 6. www.un.org/en/pdfs/
DigitalCooperation-report-for%20web.pdf.
24 OECD, Development Co-operation Report 2021, 8.
25 World Health Organization, Executive Board, 146th Session, Data and Innovation: Draft Global Strategy on Digital Health
(Geneva: WHO, February 3-8, 2020), https://apps.who.int/iris/handle/10665/336377.
26 See for example USAID’s “Vision for Action in Digital Health” (2020), the Asian Development Bank’s “Digital Health Impact
Framework” (2018) and Digital Health Implementation Guide for the Pacific (2021), Digital Square’s Global Goods Guidebook
(2022) as well the publications referenced in this report, such as WHO’s Digital Implementation Investment Guide (2020) and
OECD’s Development Co-operation Report 2021.
27 PATH, Digital Transformation to Accelerate Data Use: A Model for Success (Seattle: PATH; Washington, DC: Cooper/Smith,
forthcoming).
28 See https://digitalprinciples.org.
29 See https://healthdataprinciples.org.
30 OECD, “Recommendation of the Council on Health Data Governance” (Paris: OECD, 2016), https://legalinstruments.oecd.
org/en/instruments/OECD-LEGAL-0433.
31 Sara L.M. Davis, “Towards Digital Justice: Participatory Action Research in Global Digital Health,” BMJ Global Health 7, no.
e009351 (2022), https://gh.bmj.com/content/7/5/e009351.
32 In the literature considered and in our engagement outreach, the terms “national digital health plan” and “national digital
health strategy” appeared interchangeably. We adopted this practice.
33 See, for example, the National Digital Health Strategy of Tanzania, the National Digital Health Strategic Plan of Rwanda and
the National eHealth Strategy of Nepal.
34 World Health Organization, Engaging the Private Health Service Delivery Sector Through Governance in Mixed Health
Systems: Strategy Report of WHO Advisory Group on the Governance of the Private Sector for Universal Health Coverage
(Geneva: WHO, 2020), www.who.int/publications/i/item/9789240018327.
35 Note that the costing analysis was limited to low- and lower-middle income countries because they are most in need of
technical and financial support.
36 Based on the population across the 78 countries of around 4.1 billion
37 World Health Organization, Global Expenditure on Health: Public Spending on the Rise? (Geneva: WHO, 2021)‎, www.who.
int/publications/i/item/9789240041219.
38 The 350 interviewees represent a range of sectors and geographies and were required to be knowledgeable or have
experience working with digital health solutions. The survey outcome was validated through discussion with expert groups.
39 Based on World Bank classifications as of July 2022. This comprised 24 low-income countries and 54 lower-middle-income
countries. The Yemen, Eritrea, Democratic People’s Republic of Korea, South Sudan and Syrian Arab Republic were excluded
based on the lack of adequate data.

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40 Broadband Commission for Sustainable Development, Digital Health: A Call for Government Leadership and Cooperation
Between ICT and Health (2017), https://broadbandcommission.org/wp-content/uploads/2021/09/WGHealth_Report2017-.pdf.
41 International Telecommunication Union, Pandemic in the Internet Age: From Second Wave to New Normal, Recovery,
Adaptation and Resilience (Geneva: ITU, 2021), http://handle.itu.int/11.1002/pub/818a9814-en.
42 Based on the Conceptual Framework research conducted in Asia.
43 Corinne Grainger, A Software for Disease Surveillance and Outbreak Response: Insights from Implementing SORMAS in
Nigeria and Ghana, Abuja: Federal Ministry for Economic Cooperation and Development, 2020), https://health.bmz.de/studies/
a-software-for-disease-surveillance-and-outbreak-response. And from information shared by GIZ on 21 September 2022.
44 ITU, Pandemic in the Internet Age
45 Ministry of Health Malawi, German Agency for International Cooperation (GIZ), Federal Ministry of Economic Cooperation
and Development (BMZ), management4health, Compelling Works, Cooper/Smith, Ona (an IT company), Jembi (a South
African NGO) and HISP Malawi (operator of the national health information system, DHIS2); the latter three were partners in
the initial phase.
46 Ruth Evans, “Linking Rural Health Centres Up With Malawi’s Digital Health Architecture,” (Lilongwe: Federal Ministry for
Economic Cooperation and Development, July 2021), https://health.bmz.de/stories/linking-rural-health-centres-up-with-
malawis-digital-health-architecture/. And from information provided by GIZ on 22 September 2022.
47 Microsoft, Mastercard, Google, Orange, Zenysis, Dimagi and Living Goods are companies and initiatives that identify as
partners of the Data Science Catalytic Fund. See www.theglobalfund.org/en/updates/2022/2022-03-28-data-science-catalytic-
fund-improving-collection-and-use-of-community-health-data/.
48 Quotes from www.newtimes.co.rw/opinions/five-years-later-rwandan-government-zipline-international-have-created-
instant-logistics and www.devex.com/news/drones-can-strengthen-delivery-of-health-supplies-a-new-study-finds-102894.
Example derived from private sector outreach led by Digital Health Partnerships.
49 Broadband Commission for Sustainable Development, Working Group on Digital Health the Promise of Digital Health:
Addressing Non-Communicable Diseases to Accelerate Universal Health Coverage in LMICs (2018), www.novartisfoundation.
org/news/media-library/promise-digital-health-addressing-non-communicable-diseases-accelerate-universal-health-
coverage-lmics.
50 “Using the Leap mHealth Platform Remotely to Train Community Health Volunteers about COVID-19”. HygieneHub, 2021,
www.hygienehub.info/fr/case-studies/kenya-using-leap-mhealth-platform-remotely-to-train-community-health-volunteers-
about-covid-19.
51 Amref Health Africa, Request for Support: Scaling Up Mobile Learning Solution Leap in Ethiopia (2020), https://
elsevierfoundation.org/wp-content/uploads/2020/10/202009_Amref-proposal_Leap.pdf.
52 Paula Gilbert, “M-Tiba puts Safaricom on Fortune’s Change the World List,” Connecting Africa, September 22, 2020, www.
connectingafrica.com/author.asp?section_id=761&doc_id=764100. Example derived from private sector outreach led by Digital
Health Partnerships.
53 Digital Square, Sustainable Digital Health at Scale: EMR implementations in India (2018), https://static1.squarespace.com/
static/59bc3457ccc5c5890fe7cacd/t/608747d17eb25638c0be6ddd/1619478481795/Healthy+Market+Dynamics+Case+Study.pdf.
54 Example derived from the Eastern Mediterranean regional report.
55 This is an illustrative estimate by reference to the proportion of domestic spending to international aid spending in low- and
lower-middle income countries health spending from WHO Global health expenditure data base, and domestic investment
proportions from the Global Fund 7th Replenishment projection of available resources.
56 United States Agency for International Development, A Vision for Action in Digital Health 2020–2024: Accelerating the
Journey to Self-reliance through Strategic Investments in Digital Technologies (Washington, DC: USAID, 2020), www.usaid.gov/
sites/default/files/documents/USAID-A-Digital-Health-Vision-for-Action-v10.28_FINAL_508.pdf.
57 The Principles for Digital Development are nine guidelines designed to help integrate best practices into technology-
enabled programmes and are intended to be updated and refined over time. See https://digitalprinciples.org/.
58 Kickbusch et al., “The Lancet and Financial Times Commission on Governing Health Futures 2030”

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59 Organisation for Economic Co-operation and Development, Development Co-operation Report 2021 (Paris: OECD, 2021).
60 Belgium, Denmark, European Union, France, Germany, Japan, Republic of Korea, the Netherlands, Norway, Sweden, United
Kingdom and United States.
61 See www.who.int/initiatives/sdg3-global-action-plan.
62 Wilton Park, Private capital to achieve public health goals in Africa (2022), www.wiltonpark.org.uk/wp-content/
uploads/2022/04/Report-WP3020.pdf.
63 Medical Credit Fund Africa, www.medicalcreditfund.org.
64 OECD, Development Co-operation Report 2021.
65 OECD, Development Co-operation Report 2021.
66 Low- and lower-middle income countries as classified by the World Bank 2022-2023 classifications.
67 Global Research Consortium members include: AeHIN, HELINA, RECAINSA, ZIMAM, Philips DCCC, WEF’s Edison Alliance,
YET4H, Chatham House, FIND, PATH, GIZ, GAP Data and Digital Health Accelerator, I-DAIR, HealthEnabled, J&J, PharmAcccess,
OECD, Smart Africa, Speak Up Africa, World Bank.
68 Classification of Digital Health Interventions v1.0 was leveraged in this exercise (link following), this classification is
undergoing review and is intended to be updated in early 2023 with a version 2.0. Retrieved from https://apps.who.int/iris/
bitstream/handle/10665/260480/WHO-RHR-18.06-eng.pdf.
69 PATH, Building a Data Use Investment Road Map in Tanzania: A Look Back at What Worked (Seattle: PATH, 2017), www.path.
org/resources/building-digital-health-investment-road-map-tanzania-look-back-what-worked.
70 Kickbusch et al., “The Lancet and Financial Times Commission on Governing Health Futures 2030”
71 World Health Organization, Monitoring the building blocks of health systems: a handbook of indicators and their
measurement strategies, (Geneva:WHO, 2010)‎, https://apps.who.int/iris/handle/10665/258734.
72 Digital Square, “Digital Transformation of Health Systems in Low-resource Settings”.
73 WHO Classifications on Digital Health Interventions v01, Tanzania Data Use Partnership Investment Roadmap, The Lancet
and Financial Times Commission on governing health futures 2030: growing up in a digital world, see links above.
74 Regions include Middle East and North Africa, Eastern-Southern Africa, Asia, Western Central Africa, Latin America and the
Caribbean.
75 See https://digitalsquare.org/s/Product-Attributes.pdf.
76 See https://static1.squarespace.com/static/59bc3457ccc5c5890fe7cacd/t/60f85f249f074421d46b1f5d/1626890024524/
Digital+Square+Vital+Wave+TCO+Reference+Document_final.pdf.
77 Asian Development Bank, Digital Health Implementation Guide for the Pacific (Manila: ADB, 2021), http://dx.doi.org/10.22617/
TIM210178-2.
78 Digital Square, “Market Analytics”, https://digitalsquare.org/market-analytics.
79 Digital Square, “Market Analytics”.
80 The countries in the health impact analysis match the countries included in the cost analysis apart from: People’s
Democratic Republic of Korea, Eritrea, Eswatini, Lebanon, Federal States of Micronesia, South Sudan, Syrian Arab Republic, the
West Bank and Gaza and Yemen. These countries have been excluded from the impact analysis due to unavailable data and
combined make up approximately 2% of the total population of all low- and lower-middle income countries.
81 World Health Organization, Recommendations on Digital Interventions for Health System Strengthening (Geneva: WHO,
2019). www.who.int/publications/i/item/9789241550505; Smisha Agarwal et al, “Decision-SupportTools Via Mobile Devices to
Improve Quality of Care in Primary Healthcare Settings,” The Cochrane Database of Systematic Reviews 7, no. 7 CD012944
(2021), https://doi.org/10.1002/14651858.CD012944.pub2.
82 Katarzyna Kolasa and Grzegorz Kozinski, “How to Value Digital Health Interventions? A Systematic Literature Review,”
International Journal of Environmental Research and Public Health 17, no. 6 (2020): 2119, https://doi.org/10.3390/ijerph17062119.
83 Bergum, Nielsen, and Sæbø, “Patchworks of Logistics Management Information Systems: Challenges or Solutions for
Developing Countries?”.

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84 Neff Walker, Yvonne Tam and Ingrid K Friberg, “Overview of the Lives Saved Tool (LiST),” BMC Public Health, 13 (Suppl 3), S1,
(2013), https://doi.org/10.1186/1471-2458-13-S3-S1.
85 More than 100 peer-reviewed publications have used LiST for programme evaluation, strategic planning and advocacy:
www.livessavedtool.org/list-in-peerreviewed-journals.
86 Fritz, Herrick and Gilbert, “Estimation of Health Impact from Digitalising Last-mile Logistics Management Information
Systems (LMIS) in Ethiopia, Tanzania, and Mozambique: A Lives Saved Tool (LiST) model analysis”.
87 Integrated management of childhood illness, World Health Organization, www.who.int/teams/maternal-newborn-child-
adolescent-health-and-ageing/child-health/integrated-management-of-childhood-illness.
88 Siri Lange, Aziza Mwisongo and Ottar Mæstad, “Why Don’t Clinicians Adhere More Consistently to Guidelines for the
Integrated Management of Childhood Illness (IMCI)?” Social Science & Medicine 104 (2014): 56-63, https://doi.org/10.1016/j.
socscimed.2013.12.020; Carsten Krüger, Monika Heinzel-Gutenbrunner and Mohammed Ali, “Adherence to the Integrated
Management of Childhood Illness Guidelines in Namibia, Kenya, Tanzania and Uganda: Evidence from the National Service
Provision Assessment Surveys,” BMC Health Services Research 17, no. 1 (2017): 822, https://doi.org/10.1186/s12913-017-2781-3;
Jonathan Izudi, Stanley Anyigu and David Ndungutse, “Adherence to Integrated Management of Childhood Illnesses Guideline
in Treating South Sudanese Children with Cough or Difficulty in Breathing,” International Journal of Pediatrics, 5173416 (2017),
https://doi.org/10.1155/2017/5173416.
89 Keitel and D’Acremont, “Electronic Clinical Decision Algorithms for the Integrated Primary Care Management of Febrile
Children In Low-Resource Settings,” 845–855; WHO, Integrated Management of Childhood Illness Global Survey Report
90 Gera et al., “Integrated Management of Childhood Illness (IMCI) Strategy for Children Under Five”.
91 Gera et al., “Integrated Management of Childhood Illness (IMCI) Strategy for Children Under Five”.
92 Torsten Schmitz et al., “Effectiveness of an Electronic Clinical Decision Support System in Improving the Management of
Childhood Illness in Primary Care in Rural Nigeria: An Observational Study,” BMJ Open 12, no. 7, e055315 (2022), https://bmjopen.
bmj.com/content/12/7/e055315.info

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