a tale of politics and stars aligning analysing the sustainability of scaled up digital CORD-Papers-2022-06-02 (Version 1)

Title: A tale of politics and stars aligning: analysing the sustainability of scaled up digital tools for front-line health workers in India
Abstract: INTRODUCTION: India has become a lighthouse for large-scale digital innovation in the health sector particularly for front-line health workers (FLHWs). However among scaled digital health solutions ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India and the potential implications of these factors for sustainability. METHODS: We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context. RESULTS: The scale-up of digital solutions was facilitated by their perceived value bounded adaptability support from government champions cultivation of networks sustained leadership and formative research to support fit with the context and population. However once scaled embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance continued engagement with FLHWs and building a robust evidence base while identified in the literature as critical for sustainability did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors implementing and technical partners and donors. CONCLUSION: The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems.
Published: 2021-07-21
Journal: BMJ Glob Health
DOI: 10.1136/bmjgh-2021-005041
DOI_URL: http://doi.org/10.1136/bmjgh-2021-005041
Author Name: Singh Neha S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/singh_neha_s
Author Name: Scott Kerry
Author link: https://covid19-data.nist.gov/pid/rest/local/author/scott_kerry
Author Name: George Asha
Author link: https://covid19-data.nist.gov/pid/rest/local/author/george_asha
Author Name: LeFevre Amnesty Elizabeth
Author link: https://covid19-data.nist.gov/pid/rest/local/author/lefevre_amnesty_elizabeth
Author Name: Ved Rajani
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ved_rajani
sha: c6835bbd436fea6b9601aebee51b50b5c0a8b2c3
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/
pubmed_id: 34312147
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34312147
pmcid: PMC8728367
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8728367
url: https://doi.org/10.1136/bmjgh-2021-005041 https://www.ncbi.nlm.nih.gov/pubmed/34312147/
has_full_text: TRUE
Keywords Extracted from Text Content: sections Gujarat and KI16 MoWCD FLHWs KI13 KI11 Women people UK KI09 NDHM FLHW Siloed women nongovernmental non-FLHWs Patient Institutionalises RV Delhi' mothers Intersectoral enabler CAS and TECHO+ KS 250-300 Auxiliary Nurse Midwives Dimagi's CommCare study-a App Gujarat; CAS, KI04 KI03 KI05 CAS's Gujarat's Reproductive Child Health (RCH NSS CAS ( evaluator/academic KI17 KI02 TECHO+made AG donors KI14 AWWs patients ... KI10 required-not participants newborns Anganwadi COVID-19 Asha George @ashageorge72 hardware'(eg AWW KI12 respondents KI06 ANMs NSS ( neha. Dedoose FLHWS Tamil Nadu Neha S Singh NDHB children ...[but MA 1-1.5 NSS, CAS lines Neha S Singh http://
Extracted Text Content in Record: First 5000 Characters:Throughout the last decade, over 600 digital health pilot strategies and programmes have been introduced globally. 1 Despite the proliferation of digital health programmes, evidence on their effectiveness is limited. [2] [3] [4] Moreover, governments have found it challenging to select, scale-up, and integrate solutions into existing national systems. 5 What is already known? ► Hundreds of digital health interventions have been piloted in low-income and middle-income countries, though few have been successfully scaled. ► Among those that have progressed beyond pilot initiatives to attain scale, efforts to achieve sustainability remains elusive, particularly with regard to integration into routine health services delivery, independence from donor funding, interoperability and governance. What are the new findings? ► To successfully sustain a scaled up digital tool, it is imperative for all stakeholders, in particular governments and donors, to have an entire supportive ecosystem in place that addresses the dynamics between aspects of the digital solution, actor relationships, implementation processes and key contextual factors, with strong government leadership to align all these pieces. What do the new findings imply? ► Our findings challenge the notion that digital health programmes progress linearly from pilot to scale to sustainability, and instead explore the elements and tensions between scale and sustainability for digital health. ► With significant resources spent each year on digital health solutions that are never scaled or sustained, it is imperative that we build the evidence base on factors that lead to success in sustaining innovations in the digital health space. Scale-up refers to the increase of a programme's reach from a pilot population or experimental region to greater numbers of people over wider geographical areas. 6 Studies and frameworks examining scaling up have emerged over time with considerable commonality. [7] [8] [9] [10] Sustainability of a programme is the 'capability of being maintained at a certain rate or level.' 11 When applied to health programmes and policies, the concept of sustainability involves the continuation of inputs (eg, funding or programme activities), outputs (eg, health benefits) and a process of adaption in response to emerging needs of the system. 12 It is an emergent field of enquiry, with numerable frameworks from different disciplines and noted challenges in assessment. 10 12-16 To date, only select digital health programmes for frontline health workers (FLHWs) have scaled, 17 18 including a few in India. [19] [20] [21] The successful scale-up of these programmes raises important questions about the micro (eg, negotiations between individuals), meso (organisational processes and systems) and macro (national policy and wider context) level factors that underpin decision making on which initiatives get adopted and with what evidence. Major factors influencing scale-up have been synthesised to create our conceptual framework (discussed below, figure 1). 10 22-24 The features that influence sustainability overlap considerably with those for scale-up, but shift focus from the intervention itself to the health system's ability to plan, organise, adapt and communicate, and the broader fiscal and political environment. 25 26 To date, very few studies 27 28 have aimed to understand processes underpinning scaled digital health tools in India or elsewhere to reflect on sustainability . Emerging literature, largely from high-income settings, sheds light on the complex and multi-dimensional nature of scaling digital solutions for health, 13 29-31 as well as how the social, political and historical contexts where digital tools are implemented plays a key role in how solutions are embedded, adapted and potentially sustained within a health system. 32 33 This study aims to answer 'Why have some digital health programmes scaled, and others not, and what are the implications for sustainability in India?'. To understand the factors that underpin the scale-up and sustainability of different typologies of digital health solutions in India, we examine five FLHW digital tools ranging from direct-to-FLHW programmes to real-time data capture and decision-support tools. This analysis will benefit actors involved in the development of digital tools for FLHWs in India and other settings by illuminating the multifaceted inputs and processes involved in scale-up and by providing a framework for thinking about how the scale-up process can support or hinder the tool's chances of sustainability. Drawing case studies from India is particularly fruitful because it is the site of several of the world's largest digital programmes for FLHWs and one of the few low-income or middle-income countries that appear to be sustaining these tools. We developed a conceptual framework to study what shapes scale-up and sustainability of digital tools for FLHWs (figure 1), reflecting broader literature
Keywords Extracted from PMC Text: commonality.7–10 KI10 TECHO+made KI16 analysis.42 studies27 2015–2016 National Family Health Survey non-FLHWs newborns Dedoose national- 34–37 designs.12 15 26 51 52 evaluator/academic AG KI17 CAS ( Anganwadi FLHW Women children limited.2–4 participants patients COVID-19 KI03 MA Dimagi's CommCare Nigeria10 KI02 Gujarat and 's respondents FLHWs Zambia31 triangle.38 programmes.41 globally.1 Gujarat; KI14 programmes13 birth.40 App KS system.12 hardware'(eg KI06 assessment.10 12–16 level.'11 ANMs KI05 KI11 literate.39 people women Delhi' AWWs MoWCD enabler KI04 lines mothers phones.40 FLHWS ... CAS and TECHO+ KI13 KI12 CAS, donors 2015–2016 NHFS environment.25 CAS
Extracted PMC Text Content in Record: First 5000 Characters:Throughout the last decade, over 600 digital health pilot strategies and programmes have been introduced globally.1 Despite the proliferation of digital health programmes, evidence on their effectiveness is limited.2–4 Moreover, governments have found it challenging to select, scale-up, and integrate solutions into existing national systems.5 Scale-up refers to the increase of a programme's reach from a pilot population or experimental region to greater numbers of people over wider geographical areas.6 Studies and frameworks examining scaling up have emerged over time with considerable commonality.7–10 Sustainability of a programme is the 'capability of being maintained at a certain rate or level.'11 When applied to health programmes and policies, the concept of sustainability involves the continuation of inputs (eg, funding or programme activities), outputs (eg, health benefits) and a process of adaption in response to emerging needs of the system.12 It is an emergent field of enquiry, with numerable frameworks from different disciplines and noted challenges in assessment.10 12–16 To date, only select digital health programmes for front-line health workers (FLHWs) have scaled,17 18 including a few in India.19–21 The successful scale-up of these programmes raises important questions about the micro (eg, negotiations between individuals), meso (organisational processes and systems) and macro (national policy and wider context) level factors that underpin decision making on which initiatives get adopted and with what evidence. Major factors influencing scale-up have been synthesised to create our conceptual framework (discussed below, figure 1).10 22–24 The features that influence sustainability overlap considerably with those for scale-up, but shift focus from the intervention itself to the health system's ability to plan, organise, adapt and communicate, and the broader fiscal and political environment.25 26 To date, very few studies27 28 have aimed to understand processes underpinning scaled digital health tools in India or elsewhere to reflect on sustainability. Emerging literature, largely from high-income settings, sheds light on the complex and multi-dimensional nature of scaling digital solutions for health,13 29–31 as well as how the social, political and historical contexts where digital tools are implemented plays a key role in how solutions are embedded, adapted and potentially sustained within a health system.32 33 This study aims to answer 'Why have some digital health programmes scaled, and others not, and what are the implications for sustainability in India?'. To understand the factors that underpin the scale-up and sustainability of different typologies of digital health solutions in India, we examine five FLHW digital tools ranging from direct-to-FLHW programmes to real-time data capture and decision-support tools. This analysis will benefit actors involved in the development of digital tools for FLHWs in India and other settings by illuminating the multifaceted inputs and processes involved in scale-up and by providing a framework for thinking about how the scale-up process can support or hinder the tool's chances of sustainability. Drawing case studies from India is particularly fruitful because it is the site of several of the world's largest digital programmes for FLHWs and one of the few low-income or middle-income countries that appear to be sustaining these tools. We developed a conceptual framework to study what shapes scale-up and sustainability of digital tools for FLHWs (figure 1), reflecting broader literature on the subject.6 8 10 13 31 34–37 Our framework was adapted from the following existing conceptual frameworks by taking into account variables relevant to the implementation of digital tools in resource-constrained settings: (1) Greenhalgh et al's framework taking into account complexity of scaling-up technology-supported programmes13; (2) Gericke et al's framework which has been applied to assess the scale-up of mHealth innovations in Malawi and Zambia31; (3) Spicer et al's framework based on studying scalable health innovations' attributes in Ethiopia, India and Nigeria10 and (4) Gilson and Walt's policy triangle.38 Doing so enabled us to simplify relevant variables into four themes: (1) digital solution characteristics, (2) actor roles and relationships, (3) implementation processes and (4) context. While drawing from existing frameworks for scaling and sustaining health interventions more generally, our work particularly takes into account specific 'hardware'(eg, cloud storage) and 'software' (eg, technological partnerships) required to scale and sustain digital health solutions. In 2011, India's population was 1.2 billion, with nearly three-quarters (74%) being literate.39 Mobile phone access in India has rapidly increased, with the 2015–2016 National Family Health Survey (NHFS) reporting 90% of households having access to mobile phones. However, less than half of wom
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