Governance Pathways for Driving Digital Health Transformation

M. J. Frost et al., What Does It Take to Be an Effective National Steward of Digital Health Integration for Health Systems Strengthening in Low- and Middle-Income Countries?, Global Health: Science and Practice, 2018

This paper examines what is required for LMICs to effectively steward national digital health initiatives, ensuring their integration into health systems in a sustainable, routine, and country-owned manner. Through a comprehensive review of literature, it identifies gaps in current governance practices and offers a conceptual framework for digital health stewardship.

Key Takeaways:

1. Four Core Pillars of Digital Health Stewardship Identified: To successfully steward national digital health efforts, governance bodies should: (a) set strategic direction, (b) develop policies and procedures, (c) define roles and responsibilities, and (d) address health service delivery implications. However, evidence and guidance to support these functions—particularly beyond strategy-setting—remain limited.
2. Gaps in Strategy Execution and Alignment: While many countries have initiated national digital health strategies, they often lack a clear roadmap for execution. Establishing a well-defined vision, setting measurable goals, and ensuring alignment with national health priorities are essential for effective implementation.
3. Gaps in Policies and Procedures Guiding Digital Health Integration: While resources like WHO's National eHealth Strategy Toolkit provide useful frameworks, LMICs often face challenges adapting them to local contexts due to limited legal and regulatory infrastructure—not only for data privacy, security, and interoperability, but also for broader implementation activities such as compliance testing, workforce training, and organizational development.
4. Unclear Operational Roles and Responsibilities: There is an absence of detailed guidance on operational roles and responsibilities needed for sustainable digital health ecosystems. While WHO's toolkit provides role classifications (e.g., program management, clinical safety), countries need tailored workforce planning to support digital health governance.
5. Limited Focus on Health Service Delivery Implications: Despite the potential of digital health to enhance equity, access, and quality, there is little guidance on how to effectively integrate these tools into healthcare delivery. Key challenges include ensuring provider adoption, developing clear regulations for data access and security, and safeguarding patient rights within digital health systems.

Broadband Commission for Sustainable Development, Digital Health: A Call for Government Leadership and Cooperation between ICT and Health, 2017

This report, developed by the Broadband Commission Working Group on Digital Health and co-led by the Novartis Foundation and Nokia, examines the role of government leadership in advancing digital health through research and interviews with experts from twenty countries. It presents key findings on leadership, governance, and collaboration, featuring eight country case studies that showcase successful national digital health strategies. 

Key Takeaways:

1. Strong governance is essential for scaling digital health beyond pilot projects. Effective national stewardship ensures that digital health initiatives are not just fragmented, short-term efforts but are fully integrated into health systems, fostering sustainability and country ownership.
2. Low- and middle-income countries (LMICs) must develop clear strategies for digital health integration. Key elements include setting strategic direction, defining roles and responsibilities, and creating policies that support interoperability, data privacy, and long-term health system strengthening.
3. Stakeholder engagement is crucial for successful digital health implementation. Effective coordination across government agencies, healthcare providers, private sector partners, NGOs, and donors ensures that digital health solutions align with national health strategies and avoid fragmentation. Countries like Malaysia, Norway, Bangladesh, and Chile have demonstrated success through advisory boards, NGO partnerships, and inclusive policy-making processes.
4. Building a skilled digital health workforce is essential for sustainability. Many LMICs face a shortage of IT specialists, informaticians, and digital health program managers. Investing in workforce development—through structured training programs, public-private partnerships, and capacity-building initiatives—helps ensure long-term success. Malaysia, Nigeria, the Philippines, Belize, and Estonia have implemented workforce-strengthening initiatives to support digital health governance.

Sustainable financing models are needed to scale digital health systems. Securing long-term funding beyond donor contributions remains a major challenge. Innovative approaches, such as sin tax revenues in the Philippines, Universal Service Funds in Pakistan, and integrated digital payment systems in Brazil, offer potential solutions. Further, over-reliance on external funding, as seen in Mali, can lead to interoperability and sustainability issues.

A dedicated body within the government that is tasked with the execution of digital health strategy facilitates timeliness of decision-making with more dedicated resourcing, financing, and coordination of digital health priorities.

• Some countries have created digital health specific agencies within the Ministry of Health (Brazil and Finland), with an explicit focus on digitalization, whereas in other country contexts, an existing health agency (i.e., for health service delivery or for health insurance) takes on the mandate for health-related digitalization (India and Ghana).
• Rwanda, in contrast to the other Exemplar countries, has a government-wide digitalization approach steered through the Ministry of ICT. This model has created a network of chief digital officers placed within other Ministries. Rwanda’s MOH has a digitalization directorate that is led by a chief digital officer.

Integration of digital efforts across different government sectors (i.e., Ministries of ICT, Trade, Foreign Affairs, Public Service, Communications, etc.) facilitates alignment, coordination, and collaboration, as many advancements within the health sector come from advancement in other sectors (e.g., digital identity). 

• In Rwanda, due to the government-wide digital agency approach, chief digital officers are placed across all Ministries. These chief digital officers convene regularly to ensure cross-sectoral and ministerial alignment with the digital transformation agenda.
• In Finland, the Ministry of Finance has a digitalization coordination committee which includes representatives from all Ministries to steer national vision for digital transformation. Similarly, in India, there is a steering committee that brings together policymakers across ministries in India to provide intersectoral guidance and decision-making.

The health system inherently produces significant amounts of data; in some Exemplar countries, there is a health-specific ICT department to manage and coordinate the data and information systems, as well as broader change management. This approach also, ideally, reduces fragmentation through stronger and centralized coordination of the digital health ICT ecosystem.

• Ghana, Brazil, and Finland have ICT departments within the primary institution that are driving the digital transformation of PHC. These ICT departments are responsible for the creation, coordination, and monitoring/evaluation of the digital health systems implemented nationally and subnationally. They are also tasked with developing criteria for standards and interoperability requirements.
• India’s MOH must coordinate with–and remain in compliance with–an external ICT department. Its Ministry of Electronics and Information and Technology has two centers that develop government-owned software and coordinate with subnational-level governments to implement these tools.

Data governance requirements to ensure privacy, security, and confidentiality of personal data exist in all Exemplar countries; however, some Exemplar countries have specific agencies to regulate data governance. These regulatory bodies provide necessary oversight and accountability for ensuring compliance to key data security and privacy policies. In the Exemplar countries, these regulators are found outside of the health ministry.

• In Ghana, Brazil, and Finland, ICT departments play a role in health-specific data regulation through developing standards (as indicated above). In addition to the ICT departments, they have separate authorities for data protection outside of the MOHs that oversee compliance with data protection laws.
• In Rwanda, there is a separate data protection office within the National Cyber Security Authority that is tasked with protecting the personal data of individuals in Rwanda per the data protection law.
• In India, there are not clearly identified data regulation authorities, though there are data protection laws.

For decentralized contexts such as provinces/states or municipalities, compliance with national-level health and digitization priorities and reporting requirements is essential. Countries deploy different approaches to adhere with national policies. 

• Brazil’s health system includes a tripartite governance structure, called CIT, that assures representation and decision-making from federal, state, and municipal-levels of government, as well as other relevant health-specific agencies. CIT also has a consultative Digital Health Management Committee which drives the digitalization agenda as policies must pass through them before being implemented. Nationally, Brazil is focused on prioritizing the policy agenda and its reporting requirements; it does not mandate the use of specific software. Reporting requirements are linked to federal financing of states and municipalities, which drives compliance.
• In India, specific state-level units have been set up to facilitate subnational alignment with the national digital health priorities. These units also coordinate with the National Health Authority to contextually adapt and localize digitalization while maintaining compliance with national guidelines. These units are adjuncts to state health departments and partner with state information technology units. The federal government funds these state-level units to incentivize compliance with national digital health priorities.

Incentivizing health data reporting to federal financing facilitated subnational-level adherence to national digital health transformation goals. Subnational development efforts incentivized in this manner include digital infrastructure improvements, establishment of local digital health organizational bodies, and digitization of routine indicator reporting. 

• India has provided financing to establish state-level, digital health project management offices to ensure alignment with national digital initiatives. Moreover, it has issued for performance-based financing to incentivize adoption and compliance with the national standards.
• Brazil has incentivized federal financing for states and municipalities through health-data reporting requirements to a national PHC information system. It has also allocated financial and resources (i.e., software/hardware) to enable compliance with these reporting requirements. Notably, the government electronic health record is provided free-of-charge and there have been several digital infrastructure-focused financing mechanisms for municipalities.

In decentralized health systems, subnational governments can exercise autonomy in selecting the most appropriate software/hardware for their context. However, there may still be contexts wherein national systems/software must be used for reporting requirements. 

• In Brazil, states and municipalities can choose to adopt the software of their choice (e.g. the freely provided government electronic health record or a private sector electronic health record) as long as it meets the reporting requirements of the national government. Additionally, states and municipalities can contract with non-government partners to facilitate improved data use; For example, a municipality could adopt the government electronic health record and contract a private sector company to improve data use for decision-making using the EHR data.
• In India, digital solutions are developed by the government or by private IT innovators. India supports integrating these solutions through a sandbox that assures alignment with national digital health requirements.