Digital Health and Non Communicable Disease

The following article was authored by Dr Feisul Idzwan Mustapha and Dr Arunah Chandran for the conference, “The promise of digital health to address non-communicable diseases in low- and middle-income countries” which was convened by Wilton Park on 25 to 27 November 2019 and published in Infomed Malaysia, Issue 32, Jan- March 2020.

Introduction

“With the largest Non-Communicable Diseases (NCDs) burden occurring in low- and middle-income countries (LMICs) and leading to and perpetuating poverty, the prevention and control of NCDs is an urgent development issue. The costs to individuals and society of healthcare and loss of income-earners hampers poverty reduction and sustainable development. NCDs constrain the bottom billion in chronic poverty.”[i]

The conference “The promise of digital health to address non-communicable diseases in low- and middle-income countries” was convened by Wilton Park on 25 to 27 November 2019. The dialogue took place one year after the publication of the Broadband Commission Working Group on Digital Health report, which highlighted the promise of digital health to address NCDs to accelerate Universal Health Coverage (UHC) in LMICs. It also followed-up on the United Nations High Level Meeting on UHC that took place in September 2019, with its focus on primary healthcare.

The conference explored the potential of national digital health strategies and systems that can offer cost-effective solutions, harnessing the full power of information and communication technologies (ICT) for the prevention, treatment and management of NCDs to improve health outcomes. Discussions also focused on how digital solutions can contribute at primary healthcare levels and through better integrated systems.

Digital technology is already revolutionising healthcare delivery and offers a way forward. Worldwide, digital tools are leading to better and faster healthcare; healthcare that is more empowering and accessible for patients, more efficient for providers and most cost-effective for health systems. Digital health is potentially the most powerful enabler that LMICs can use to address the growing burden of NCDs and achieve UHC; whether supporting prevention or treatment, management and control.

Despite their potential, the myriad of digital health solutions are often designed and rolled out with a narrow, tactical scope (e.g. a specific disease, geographic location, or patient sub-population), and consequently struggle to progress beyond the pilot phase, to become financially viable and integrate into national health policies and systems. There are also a range of challenges to consider, including data privacy, access to digital health for the most vulnerable, or for those in humanitarian settings, or how digital might apply to different demographics e.g. it might appeal less to older generations.

Malaysia was invited to participate as well as present a plenary paper. In this article, we share the key points of our paper on Malaysia’s experiences, particularly on lessons learnt. The following is some of the excerpts:

Malaysia’s Experience

“Like many developing countries, the burden of NCDs in Malaysia are high and continue to increase. There are many epidemiological transitions that are taking place contributing to the increasing burden in Malaysia. These includes a rapidly ageing population, poverty, rapid urbanisation, and the population perceiving health as low priority.

The 4^th industrial revolution was widely adopted by the government in Malaysia. A lot has been said on the use of big data, artificial intelligence, 5G, and internet-of-things. Digital health solutions have been touted by many parties to be the panacea to the many challenges faced by the health system. While the theory makes a lot of sense, the challenge remains in the implementation, in particular, the details of the implementation.

We must always remember that digital health solutions are just tools. As an analogy, the smart phone that all of us in this room probably have, is a very smart and intelligent tool. However, the utility of the smart phone relies heavily on the “smartness” or intelligence of the users.

Recently, there was an online article on how South Africa is caught in the global hype of the fourth industrial revolution which is distracting it from the unfinished business of redressing inequality and creating the preconditions for an inclusive digital economy and society.” “South Africa” could easily be swapped for any LMICs, particularly Malaysia. Digital Health Solutions may be the solution to reduce the burden of diseases in any country, however, if we are not careful in the implementation, it may further widen the inequality that already exists in the population.

This is particularly relevant for NCDs, where the burden and exposure to NCDs are not distributed equally amongst the population. There are vulnerable groups such as the B40 population who are more exposed to NCD risk factors and therefore have higher burden and higher risk of premature mortality due to NCDs. We therefore have to be more cognisant of the segment of society who would utilise the digital health solutions and gain the most benefit. For example, many digital solutions in health are often utilised by those with a higher health literacy, the converted audience. What we really need is something that works with people who need it the most.

Coming back to Malaysia, we are very much at infancy stage when it comes to successful implementation of digital health solutions. While there are many solutions that are being proposed, very few are implemented nation-wide in a sustainable manner. In addition, many of these proposed digital health solutions are more focused in the area of disease management and the aspects of the delivery of care. There are not many solutions that exists that focuses on the prevention aspects of NCDs in particular, addressing the behavioural risk factors.

We believe that these may be some of the challenges:

1. Addressing behavioural change is not easy – as there are many influences including culture, religion and belief systems;
2. No one likes to change – even if the changes are for the better. It is therefore important to understand how the population/ community/ individual will engage with the digital health solutions;
3. Digital solutions also require substantial investment up front, despite massive savings in the future; and
4. There is also an important need for a supporting environment or ecosystem.

Let us share with you, what are some of the key learnings we’ve had in our smaller scale implementation of digital health solutions:

1. We need strong leadership and advocacy. We need the champions to be the agent of change. As we have mentioned earlier, “no one likes to change”;
2. Invest in capacity building. Capacity building is not just about technologists in digital health, but also experts in change management, strategic communication and behavioural scientists. Digital health solutions are not simply not about the “tech” or the tools, but also understanding the users and how they would engage with the digital health solutions, and also understanding the environment or ecosystem in which the digital health solution is being utilised;
3. We need to develop an ecosystem that allows innovation and the use of digital health solutions (not business-as-usual);
4. Co-creation is something that is very important. Involving the intended target group in the development of the solutions not only assured you that you are addressing the actual needs from the perspective of the population but will certainly promote shared ownership. Share ownership is crucial for sustainability;
5. The need for supporting infrastructure. The country also needs the supporting infrastructure for the tech itself, particularly regular power supply and connectivity;
6. Promote public-private partnership. Digital health solutions are being advanced the private sector, and therefore as governments, we must promote public-private partnerships (or PPP). However, PPP cannot simply just be lip service. We, as the government, needs clear rules of engagement, and good governance, that includes accountability and transparency; and
7. Monitoring and evaluation (M&E) is critical and these M&E activities must be planned even during the planning stage of implementation and budgeted appropriately. M&E must include components of costing and economic evaluations as these will assist policymakers in making the decision to sustain and scale the digital health solutions throughout the country.

Malaysia is just at beginning on this digital health journey, particularly in the area of prevention of NCDs. The Ministry of Health is working with many collaborators to develop innovative solutions for NCDs. One such example is the Prosperity Fund: Better Health Program, which is a development fund approved for improving population health in selected LMICs. For the implementation in Malaysia, we have focused the project into the main scopes:

1. Focusing on the prevention of NCDs, away from the healthcare facility;
2. Co-creation of the solutions; and
3. Using digital health solutions as part of the intervention, but also in capacity building of the community health volunteers.

We cannot simply rely on old solutions to address new problems. We need new and innovative solutions, and we hope to continually learn, adopt and evolve our solutions to meet current and future needs in the country.”

Conclusion

The dialogue discussed the issues under various themes, including developing national strategies, new partnerships and financing models. In the closing session, next steps on digital health for NCDs were discussed, including ways to further the development of digital health networks in LMICs. Many experiences and lessons were shared about how NCD health care can be improved through digital solutions in LMICs, and several opportunities were identified to enable new and expanded programmes.

For Malaysia, we will continue to connect diverse partners involved in digital health and NCDs, and create new networks to enable collaborative efforts.

[i] “NCDs,” NCD Alliance, accessed 18 March 2019, https://ncdalliance.org/why-ncds/NCDs