Factors influencing the sustainability of digital health interventions in low-resource settings: Lessons from five countries.

Digital health – which includes the development and use of digital technologies and data to improve health outcomes [1] – has emerged in the past decade as a potential ‘game changer’ for enabling accessible, affordable and effective health care for all [2]. Digital health projects often involve relatively modest mobile technologies, such as short messaging service (SMS) text messaging, to address some of the most persistent barriers in health systems such as distance to services or cost [3,4]. Optimism about the potential value of digital health resulted in a flurry of pilot implementation projects undertaken over the past decade. Alas, the majority of these have failed to translate into scaled, routine services, leaving many health leaders cautious and uncertain of how to proceed [5,6]. Despite the obvious potential, there are inherent complexities that beset implementation, starting from the source of the concept (who decided on a digital intervention? on what grounds?) through to assessing the impact (who benefited? who didn’t? how do we know?). In this paper, we draw on experiences in designing, implementing and evaluating digital health initiatives within low resource settings to identify lessons learned about factors that can influence successful and sustainable integration of digital health within local health systems. These experiences include digital health initiatives in Samoa [7], India [8], Kenya [9], Tanzania [7] and New Zealand [10] which were each undertaken in partnership with local health system providers, senior policy leads and local telecommunications providers (Table 1). Each intervention was ostensibly designed to ensure that digital health intervention improved the specific targeted health outcomes and could be integrated with existing health systems in a sustainable manner [5].