With digital transformation sweeping almost every sector, we are seeing major changes in the world of work. In fact, there is a lot of fear about the elimination of jobs—from bank tellers to travel agents to taxi drivers. But in healthcare—when we just don’t have enough frontline health workers—this instead creates a major opportunity. How can we use technology to optimize when and where we use our very precious human resources for health?
We can begin to imagine: what could health services look like in the digital age? And how can we ensure that health workers are supported, and not simply disrupted?
On 17 November 2021, the Center for Health Worker Innovation convened a conversation to discuss this important topic. Moderated by Jenny Lei Ravelo from Devex, it featured a panel of speakers including Amnesty Le Fevre from the University of Cape Town, Aparna Hegde from ARMMAN, Edward Booty from Reach52, and Nakululombe Kwendeni from mothers2mothers. The panel represented diverse perspectives from research, program implementation, technology development, and frontline healthcare.
Despite the potential of technology to extend access to care, the panel discussed several important barriers at the client, health worker, and health system level that are still to be overcome before this vision can be fully realized. They also offered some practical tips for supporting health workers and provided their perspectives on where strategic investment is required.
Barriers for clients
Before a digital health service can achieve its health aims, it first needs to reach its target audience. Unfortunately, many existing digital health programs fail to connect with clients to deliver their intervention as intended. Despite the surge in mobile ownership and use over the last decade, the gender gap in mobile phone ownership is still significant, with less than half of women owning phones in several countries. This gap tends to be larger for rural and poorer women. In addition, access to a handset isn’t enough to determine phone use—this is influenced by a host of factors from technical literacy through to self-efficacy and societal norms around female phone use. There is also a significant challenge of ‘SIM card churn’—particularly among those with lower socio-economic status using ‘pay-as-you-go’ payment models—resulting in incorrect mobile phone numbers within health databases. All these factors combine to create a real risk that digital health services may perpetuate health inequities for vulnerable groups.
In addition, clients may be fearful of providing accurate phone numbers due to the risk that unexpected incoming messages or phone calls may inadvertently reveal sensitive health information to their family or community members.
The evidence on scaled client-facing digital messaging services (like Kilkari in India) suggests that these population-level interventions are only able to shift a small subset of behaviors. They remain a blunt instrument, lacking the targeted content and personalization required to drive meaningful changes in empowerment and behavior.
Barriers for health workers
Health worker perspectives on digital health services have been less studied, but the panelists raised several challenges from their implementation and research experience. For example, while some programs issue health workers with mobile phones for professional use, others require health workers to use their personal devices. This, coupled with the widespread use of informal messaging services for communication with peers and clients, can result in medical images and conversations being automatically archived in a health worker’s personal camera roll or message history. Many health workers are also required to use their own mobile airtime for work purposes. This blurring of boundaries can create a feeling of unease among health workers, with the risk of privacy and confidentiality breaches, and additional financial responsibilities.
Some health workers experience the same challenges with technical literacy as their clients. In addition, when digital tools have been designed primarily to obtain data for health system managers, they can place a burden on health workers without adding any value at the point-of-care for health workers or patients.
Some health workers also see digital technologies as ancillary—a “nice-to-have”—rather than foundational to their work of service delivery. They can more easily see the value of addressing other health system challenges, such as the layout of health facilities, than investing in digital transformation.
Health system barriers
At a systems level, the COVID-19 pandemic remains a challenge that has overwhelmed health leaders around the globe, delaying and interrupting many other health investments. There is a lack of sustainable financing for digital health services, and a heavy reliance on civil society to supplement even basic service delivery.
Governments often fail to provide strong governance around the use of data and digital services, including setting of standards for interoperability within and across facilities, and establishing processes for protecting informed consent and ensuring service quality. While data protection legislation is becoming more common, enforcement is still weak. This, in turn, erodes patient trust in digital health services, particularly with regards to health conditions with ongoing stigma, like HIV.
Supporting health workers
Despite these barriers, the panelists described some of the practical things that organizations and governments can do to support health workers during the introduction of digital tools. For example, they can ensure that health workers have an additional stipend for mobile airtime and data bundles to cover their work-related activities.
During the design of digital health services, it can be useful to think about a holistic suite of products targeting both clients and health workers, so that health workers are supported to play their role in the continuum of care. This might include job aids for health workers that guide them step-by-step on exactly how to manage high-risk cases identified from communities. Adopting a human-centered design approach is as important when designing for health workers as it is when designing for clients and communities.
While the adoption of digital tools by health workers may be accelerated by a top-down mandate from health system leaders, a bottom-up way to encourage adoption can be to introduce individual health worker incentives based on improved client health outcomes, which are tracked through digital tools. It can also be valuable to assign health workers a ‘digital buddy’ to help them with initial onboarding.
Investing for the future
When asked to describe their vision for the future and where investment is required to drive progress, the panel described digital health services that offer much more targeted, personalized experiences, with locally contextualized content and strong linkages to care. Digital health services need to reinforce a relationship with clients built on trust and empowerment, rather than undermining this human element.
Digital transformation of healthcare has been slower than some other sectors, but it is undoubtedly happening, and it is now up to all of us to ensure that it delivers the future that we want - creating increased access and convenience for patients and communities, easing the burden for health workers by optimizing exactly where they spend their time and effort, and enabling seamless linkages across the continuum of care.