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Digital technology and health governance

Digital technology has the power to transform healthcare in developing countries, but only if it’s used properly.

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Digital technology has the power to revolutionise health care in developing countries. Its mercurial ability to gather data, monitor patients, get the right medicines to the right people and hold providers accountable can save and transform lives. At least, it can if you know how to use it.

But millions of sick people in developing countries could be missing out on the benefits of digital technology because aid workers and health providers don’t understand how to apply it.

And according to a new study co-authored at Cambridge Judge and published in the Journal of Global Health, poor governance means some digital initiatives are missing the mark by so much – by not supporting new ICT (information and communications technology) tools in medical administration services with the necessary infrastructure, for instance – that many services may even be better left offline.

“Digital technology has provided fantastic tools which can gather data, while making services more transparent and providers more accountable,” says Cambridge Judge PhD candidate Isaac Holeman. “But while many bosses think this automatically leads to improved health provision, it doesn’t when there is a lack of engagement on the ground. You need good governance in place alongside the technology for it to be effective.”

“Common uses of ICT for good governance in the health sector in low and middle-income countries can be grouped into four categories,” says Holeman. “These are gathering information, aiding communication, mobilising citizens and automating systems. Yet when we studied reports into how ICT is applied, they tended to emphasise data or transparency alone, with the implicit assumption that improvements in the quality or equity of health services would inevitably follow. But they don’t.”

Holeman and his research colleagues – Tara Cookson from the University of Cambridge’s geography department and Claudia Pagliari from the University of Edinburgh – studied dozens of articles and other research papers, which identified many digital technologies in place in the governance of low and middle-income countries health services. These included mobile apps, digital mapping, GPS, analytical software, fingerprint scanning, interactive websites, social media and finance-tracking systems. As well as boosting direct healthcare provision, the many benefits include tackling corruption by ensuring medicines get to the right patients, auditing payments and checking that workers make scheduled visits to patients.

And in some places, thanks to good governance, these tools are used effectively: patients in Guatemala use SMS texts to report discrimination by health workers against indigenous people; the Quipu Project in Peru enables victims of a forced sterilisation programme that took place in the 1990s to use digital tools to speak about their experiences; UNICEF’s social platform U-Report, which polls patients’ satisfaction with their health service, has a million registered users in Uganda alone.

But many other schemes are losing their potential effectiveness because those who launch them do not take into account the people they are specifically trying to help, finds the report. “It should not be assumed that digital technologies or eGovernment platforms will deliver good governance–related benefits unless they explicitly address specific and measurable concerns with performance or facilitate concrete mechanisms of responsive governance,” says Holeman. “Some developing countries are limited by lower mobile phone usage or internet access, particularly among women and vulnerable groups, which further marginalises them. Understanding local patterns of technology is therefore vital when determining which components of good governance should be digitised and which are better left offline. You need to do ethnographic studies, go where the action is, implement feedback systems, to understand the local issues and whether such digitisation will work.”

Getting that feedback is vital, says US-based charity Management Sciences for Health, whose mission is to “close the gap between knowledge and action in public health” in developing countries. “New digital technologies are increasingly available to support a two-way flow of timely and accurate ideas, insights, and information among stakeholders for planning and performance monitoring, and perhaps more importantly for cultivating accountability,” says technical director Mahesh Shukla.

“Citizen involvement in the monitoring of health services, e.g. reporting on the availability of medicines and vaccines, stock-outs, waiting time at clinics, whether equipment is functional or not, etc. is an example of how digital technology combined with good governance and sound management, could transform the health service delivery and health service user experience.”

Holeman’s own non-profit tech company, Medic Mobile, uses digital tools for a range of actions including disease surveillance, childhood immunisations, antenatal care and drug stock monitoring. But while he describes the firm’s work as “seeing complex health systems from the perspective of the poor and marginalised, and responding pragmatically”, his research shows many providers’ initiatives to introduce digital technology do not take into account that same perspective – and lose effectiveness as a result. He urges policymakers to examine how they are using digital technology to “complete action cycles rather than settling for transparency or better information alone. Too many people think more technology is a silver bullet, cookie cutter solution,” he says. “It can be, but only if it’s supported by good governance.”