Abstract
BackgroundWith the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application).ResultsA framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by ‘champions’; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions.ConclusionsThere is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems.
Highlights
In sub-Saharan Africa, the number and scope of digital solutions used in health is rapidly increasing
Cases are presented in order of initial implementation, beginning with Perinatal Problem Identification Programme (PPIP) and Child Child Healthcare Problem Identification Programme (PIP), followed by MomConnect that was implemented in its current form at national scale in 2014
At the time of interviews, the CommCare application was selected for implementation at a national scale to support the work of community health worker (CHW) who form part of the ward-based primary healthcare outreach teams (WBPHCOTs) in over 20 President’s Emergency Plan for AIDS Relief
Summary
In sub-Saharan Africa, the number and scope of digital solutions used in health is rapidly increasing. In South Africa, these include a policy environment that supports innovation with oversight over the delivery of digital programmes and services, skilled and experienced technical partners, high levels of mobile phone penetration, gender parity in phone access, moderate to high levels of digital literacy, and the availablity of resources necessary to support digital solutions' development and use [2,3,4,5,6] Despite such advantages, very little attention has been paid to understanding the processes that underpin efforts to scale up and sustain digital health solutions in South Africa or elsewhere [7, 8]. With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application)
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