Can digital technology help reinvent primary healthcare in support of universal health coverage?

Achieving universal health coverage (UHC) – quality, accessible, affordable health services for everyone – has been on the global agenda for many years. Still, in the majority of countries it remains a lofty goal requiring ongoing commitment from the global health community on many fronts.

Primary healthcare (PHC) has a unique role to play, not just in ensuring appropriate care for individuals in their communities, but also being on the front-lines against global threats including disease outbreaks and antimicrobial resistance. In November last year, UN Member States defined PHC as “a cornerstone of a sustainable health system for UHC,” as they reaffirmed their commitment to it in the Declaration of Astana – 40 years after the Declaration of Alma-Ata first championed health for all.

Those working in PHC face a unique set of challenges. Most often, patients present with non-specific symptoms, such as fever – leaving healthcare professionals faced with a raft of decisions to make about possible courses of action, such as running diagnostic tests, administering treatment, or referral to a hospital or a specialist clinic. Those decisions are the first step along the whole patient pathway, directly impacting patient experiences and outcomes, as well as health system efficiency and sustainability.

To optimize patient care and enable better monitoring and deployment of health system resources, tools and protocols to support and harmonize PHC decision-making have been developed. One example is the Integrated Management of Childhood Illness (IMCI) algorithm, designed by WHO and UNICEF to encourage healthcare professionals to take a holistic approach to the variety of factors that put children’s health at serious risk. IMCI supports the combined treatment of major childhood illnesses, as well as emphasizing prevention of disease through immunization and improved nutrition.

Use of digital health applications has been shown to improve guideline adherence, reduce antibiotic over-prescription rates, and improve patient outcomes, and point-of-care electronic clinical decision-support algorithms (eCDAs) hold particular potential in resource- and connectivity-challenged settings. As an example, IeDA (Integrated e-Diagnostic Approach) is a tablet-based tool being developed and implemented by Terre des hommes foundation (Tdh), which has helped health personnel diagnose 1.6 million children in Burkina Faso in 2018. Use of the tool has been shown to increase adherence to the IMCI protocol by 50%, reduce antibiotic over-prescription by up to 15% and decrease the recurrent costs of the health system.

However, the potential of eCDAs largely remains untapped. FIND recently conducted an analysis of clinical algorithms and guidelines used to manage febrile patients in low- and middle-income countries, concluding that, with the exception of IeDA, various digital tools have been developed to support algorithm implementation without the intention of national or international expansion, creating a redundant and inefficient system unable to maximize impact in many countries – thus resulting in low levels of adoption.

To address these and other challenges, WHO released its first guideline on digital health interventions last month. This guideline provides renewed impetus for the community to develop a shared vision on how these tools can improve global health. FIND is also working with WHO on the development of a target product profile (TPP) for a toolkit that includes eCDAs and diagnostic tools, designed to provide guidance on eCDA characteristics that could help optimize their effectiveness, efficient implementation, sustainability, and impact measurement – also keeping in mind the potential to add more diagnostic tests that would improve patient management further.

World leaders and global health stakeholders will convene shortly at the 72nd World Health Assembly (WHA) in Geneva, Switzerland. A dedicated side meeting on 23 May 2019 will bring together stakeholders including funders and implementers to discuss how formalizing clinical decision electronic tools through the introduction of guidelines to ensure key criteria are met will ensure smooth integration of old and new technologies, and enable development and country adoption of tools that are evidence-based and impactful on clinical care. Participants will consider the importance of quantifying the impact of tools like IeDA, and explore how to sustain that impact in order to benefit health systems.

Quality decision-making in PHC can often be difficult, but is always vital. Harnessing the increasing ubiquity of digital technologies in the community to advance and improve PHC is a major opportunity to accelerate progress towards UHC.

About the authors:

Riccardo Lampariello is Head of Health Programme of Terre des hommes, the leading Swiss organization for children’s aid that provides assistance to over four million children and their families in more than 45 countries each year.

Sabine Dittrich is Head of Malaria & Fever of FIND (the Foundation for Innovative New Diagnostics), a global non-profit organization driving innovation in the development and delivery of diagnostics to combat major diseases affecting the world’s poorest populations.

Competing Interests :

All authors have read and understood the BMJ Group policy on declaration of interests and declare they have nothing to declare.

 

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