Using Technology to Advance Global Health: Proceedings of a Workshop

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USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

PROCEEDINGS OF A WORKSHOP

Rachel M. Taylor and Joe Alper, Rapporteurs

Forum on Public—Private Partnerships for Global Health and Safety

Board on Global Health

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This project was supported by Anheuser-Busch InBev; Becton, Dickinson and Company; Bill & Melinda Gates Foundation; Catholic Health Association of the United States; ExxonMobil; Fogarty International Center of the National Institutes of Health; General Electric; Global Health Innovative Technology Fund; Intel Corporation; Johnson & Johnson; Medtronic; Merck; Novartis Foundation; PATH; PepsiCo; Procter & Gamble Co.; The Rockefeller Foundation; Safaricom; United Nations Foundation; University of Notre Dame; UPS Foundation; U.S. Agency for International Development; U.S. Department of Health and Human Services Office of Global Affairs; U.S. Department of State; U.S. Food and Drug Admin- istration; Verizon Foundation; and The Vitality Group. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Using technology to advance global health: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24882.

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PLANNING COMMITTEE ON USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH1

ANN AERTS (Co-Chair), Head, Novartis Foundation ELAINE GIBBONS (Co-Chair), Executive Director, Global Corporate Engagement, PATH ROBERT BOLLINGER, Professor of Infectious Diseases, Johns Hopkins University School of Medicine REZA JAFARI, Chairman and Chief Executive Officer, e-Development International ANNA THOMPSON-QUAYE, Senior Director Business Development & Strategic Partnerships, access.mobile International

1 The National Academies of Sciences, Engineering, and Medicine’s planning commit- tees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for this published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

FORUM ON PUBLIC–PRIVATE PARTNERSHIPS FOR GLOBAL HEALTH AND SAFETY1

JO IVEY BOUFFORD (Co-Chair), President, The New York Academy of Medicine CLARION JOHNSON (Co-Chair), Private consultant, ExxonMobil ANN AERTS, Head, Novartis Foundation SIR GEORGE ALLEYNE, Director Emeritus, Pan American Health Organization; Chancellor, University of the West Indies RAJESH ANANDAN, Senior Vice President, Strategic Partnerships and UNICEF Ventures, U.S. Fund for UNICEF NATASHA BILIMORIA, Director, U.S. Strategy, Gavi, the Vaccine Alliance DEBORAH L. BIRX, U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy, U.S. Department of State, U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) SIMON BLAND, Director, New York Liaison Office, UNAIDS ROBERT BOLLINGER, Professor of Infectious Diseases, Johns Hopkins University School of Medicine STEPHEN CHEGE, Director, Corporate Affairs, Safaricom GARY M. COHEN, Executive Vice President and President, Global Health and Development, Becton, Dickinson and Company (until February 2018) BRENDA D. COLATRELLA, Executive Director, Corporate Responsibility, Merck; President, Merck Foundation BRUCE COMPTON, Senior Director of International Outreach, Catholic Health Association of the United States PATRICIA DALY, Associate Vice President, Global Health, Save the Children KATE DODSON, Vice President for Global Health Strategy, United Nations Foundation JENNIFER ESPOSITO, Worldwide General Manager, Health and Life Sciences, Intel Corporation RENUKA GADDE, Vice President, Global Health, Becton, Dickinson and Company ELAINE GIBBONS, Executive Director, Global Corporate Engagement, PATH ROGER GLASS, Director, Fogarty International Center

1 The National Academies of Sciences, Engineering, and Medicine’s forums and round tables do not issue, review, or approve individual documents. The responsibility for this published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.

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DANIELLE GREENBERG, Senior Director, Global R&D; Senior Fellow, Nutrition Sciences, PepsiCo RICHARD GUERRANT, Thomas H. Hunter Professor of International Medicine, University of Virginia TREVOR GUNN, Vice President, International Relations, Medtronic JESSICA HERZSTEIN, Consultant, U.S. Preventive Services Task Force BEN HOFFMAN, Chief Medical Officer, GE Energy A. REZA JAFARI, Chairman and Chief Executive Officer, e-Development International JAMES JONES, Manager, Community Investment Programs, ExxonMobil ALLISON TUMMON KAMPHUIS, Leader, Children’s Safe Drinking Water Program, Social Sustainability, Procter & Gamble Co. ROSE STUCKEY KIRK, President, Verizon Foundation SEEMA KUMAR, Vice President, Innovation, Global Health & Science Policy Communication, Johnson & Johnson MARISSA LEFFLER, Center for Accelerating Innovation and Impact, U.S. Agency for International Development EDUARDO MARTINEZ, President, UPS Foundation JOHN MONAHAN, Senior Advisor to the President, Georgetown University MICHAEL MYERS, Managing Director, The Rockefeller Foundation ANDRIN OSWALD, Director, Life Sciences Partnerships, Bill & Melinda Gates Foundation REGINA RABINOVICH, ExxonMobil Malaria Scholar in Residence, Harvard T.H. Chan School of Public Health SCOTT C. RATZAN, President, Anheuser-Busch InBev Foundation B. T. SLINGSBY, Chief Executive Officer and Executive Director, Global Health Innovative Technology Fund KATHERINE TAYLOR, Associate Director and Director of Global Health Training, Eck Institute for Global Health, University of Notre Dame MARY LOU VALDEZ, Associate Commissioner for International Programs, Director, Office of International Programs, U.S. Food and Drug Administration DEREK YACH, Chief Health Officer, The Vitality Group (until September 2017) TADATAKA “TACHI” YAMADA, Venture Partner, Frazier Healthcare Partners

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Health and Medicine Division Staff RACHEL TAYLOR, Senior Program Officer and Forum Director PRIYANKA NALAMADA, Research Associate KATHERINE PEREZ, Senior Program Assistant DANIEL CESNALIS, Financial Associate JULIE PAVLIN, Director, Board on Global Health

Consultant JOE ALPER, Science Writer

Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineer- ing, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings:

MAGNUS MORDU CONTEH, World Vision International ALAIN LABRIQUE, Johns Hopkins Bloomberg School of Public Health ALICE LIU, mPowering Frontline Health Workers

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by GARRETT MEHL, World Health Organization. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

Acknowledgments

A number of individuals contributed to the development of this workshop and proceedings. These include a number of staff members from the Health and Medicine Division and the National Academies of Sciences, Engineering, and Medicine: Daniel Cesnalis, Faye Hillman, Sarah Kelley, Priyanka Nalamada, Julie Pavlin, Katherine Perez, Bettina Ritter, and Rachel Taylor. The planning committee contributed several hours of service to develop and execute the agenda. Reviewers also provided thoughtful remarks in reading the draft manuscript. The overall successful functioning of the Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) and its activities depends on the generosity of its sponsors. Financial support for the PPP Forum is provided by Anheuser-Busch InBev; Becton, Dickinson and Company; Bill & Melinda Gates Foundation; Catholic Health Association of the United States; ExxonMobil; Fogarty International Center of the National Institutes of Health; General Electric; Global Health Innova- tive Technology Fund; Intel Corporation; Johnson & Johnson; Medtronic; Merck; Novartis Foundation; PATH; PepsiCo; Procter & Gamble Co.; The Rockefeller Foundation; Safaricom; United Nations Foundation; Univer- sity of Notre Dame; UPS Foundation; U.S. Agency for International Devel- opment; U.S. Department of Health and Human Services Office of Global Affairs; U.S. Department of State; U.S. Food and Drug Administration; Verizon Foundation; and The Vitality Group.

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Contents

ACRONYMS AND ABBREVIATIONS xv

1 INTRODUCTION 1 The Role of Digital Health, 2 Organization of the Proceedings, 5

2 DIGITAL HEALTH WITHIN THE CURRENT GLOBAL CONTEXT 7 Open Discussion, 12

3 ENABLING A MULTIDISCIPLINARY APPROACH TO HEALTH 17 Multidisciplinary Business Models for Digital Health, 18 World Café Discussions, 22

4 COUNTRY-LEVEL DIGITAL HEALTH STRATEGIES 25 Engaging Digital “Teenager” Companies in Global Health, 26 PATH’s Digital Health Initiative, 29 Implementing a National eHealth Strategy in Nigeria, 31 Asia eHealth Information Network, 32 Potential Opportunities to Achieve Scale, 34 Discussion, 35

xvi CONTENTS

5 PUSH VERSUS PULL AT THE COMMUNITY LEVEL 39 Social Mobile Media to Connect, Train, Manage, and Empower Health Workers, 41 Value Proposition for Pulling Data from the Community, 43 Bottom-Up Innovation to Improve Patient Engagement, 48 Discussion, 49

6 TAPPING INTO GRASSROOTS INITIATIVES AND ENTREPRENEURS 53

7 FINAL THOUGHTS 57

APPENDIXES A References 59 B Workshop Agenda 61 C Speaker and Moderator Biographical Sketches 69

BOX AND FIGURES

BOX 1-1 Statement of Task, 4

FIGURES 2-1 The cascade of health interventions for any disease, 9 2-2 IT opportunities for health interventions for any disease, 9

4-1 Trends in malaria case reporting in southern Zambia over several rainy seasons, 28

5-1 Graphic illustration of recommendations to improve the use of digital information to advance global health, 47

Acronyms and Abbreviations

AeHIN Asia eHealth Information Network

BMGF Bill & Melinda Gates Foundation

CDC U.S. Centers for Disease Control and Prevention

DALY disability-adjusted life year DHIS District Health Information Software

ECAP Ebola Community Action Platform EHR electronic health record

FDA U.S. Food and Drug Administration

ICT information and communication technology IT information technology ITU International Telecommunication Union

LMIC low- and middle-income country

mHealth mobile health

PAHO Pan American Health Organization PPP public–private partnership

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xviii ACRONYMS AND ABBREVIATIONS

SDG Sustainable Development Goal

UK United Kingdom UN United Nations USAID U.S. Agency for International Development

WHO World Health Organization

Introduction1

Current global health priorities, such as the targets of the United Nations (UN) Sustainable Development Goals (SDGs), are ambitious. Setting an agenda for the next 15 years, targets have been established to drastically reduce maternal mortality and premature mortality from noncommunicable diseases; end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases; achieve universal health coverage; and ensure universal access to sexual and reproductive health care services, among others. While vast improvements have been made in global health in the past decades, the health challenges that weigh disproportionately on low- and middle-income countries (LMICs) continue to stand as a barrier to achieving poverty reduction and economic prosperity. Meeting these ambitious targets calls for innovative approaches. In this regard the global health community has recognized the value of digital technology as a transformational tool to accelerate progress in improving global health outcomes. Digital solutions can increase progress toward better health outcomes in LMICs through speed and reach, while increasing access to goods and services in a more people-centric, affordable, and sustainable way, said

1 The planning committee’s role was limited to planning the workshop, and this Proceed- ings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

2 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

Ann Aerts of the Novartis Foundation in her introductory remarks. She noted that digital technologies can also increase the quality of care in LMICs by centralizing expertise and coaching less-skilled health workers by phone, for example. Additionally, digital technologies can reduce inefficiencies by reducing unnecessary referrals to hospitals. As an example of the latter, she explained how a physician or trained nurse could coach a community health worker on how to assist a mother in labor instead of sending her on a 9-hour journey over bumpy roads to the hospital to deliver her child. “I am passionate about digital health not only because it is expanding access,” said Aerts, “but you can put power in the hands of patients themselves. You can empower patients to take more responsibility in the management of their own health.” She added that digital health can empower providers too by supporting them with clinical decision support and remote learning for continuous education. Digital solutions that contribute to the social, economic, and environmental dimensions of sustainable development can provide attractive business opportunities. Companies in the health and technology sector have core competencies that can be leveraged and the prospect of the value creation for investing in digital health may create incentives for multisectoral involvement. Additionally, both the public and private sectors can find value in developing partnerships with a digital health focus. Public–private partnerships (PPPs) have the potential to promote a multidisciplinary approach to developing solutions, which is ultimately beneficial to all partners and the countries in which they operate. How- ever, as several workshop speakers emphasized, understanding the incentives, priorities, expectations, and core competencies of each stakeholder is essential for identifying effective solutions.

THE ROLE OF DIGITAL HEALTH Digital health, Aerts explained, encompasses all concepts and activities at the intersection of health and information and communication technology (ICT), including mobile health (mHealth), health information technology (IT), health information systems, wearable devices, telehealth, and telemedicine. The three main areas of digital health include the delivery of health information to health professionals and health consumers through the Internet and telecommunications; using ICTs to improve public health services, such as through education and training of health workers; and using health information systems to capture, store, manage, or transmit information on patient health or health facility activities. Applications of digital health are being used to reduce inefficiencies, improve access, reduce costs, increase quality, and personalize care (FDA, 2017). However, despite the growth of the digital health sector, communi-

INTRODUCTION 3

ties in LMICs often miss out on the benefits of digital health’s potential (Lancet, 2012). LMICs continue to face a fragmented digital health landscape in which multiple public and private actors and agencies with varied technologies and interests are working separately and with overlap (Broadband Commission for Sustainable Development, 2017). Other factors that may lead to this fragmentation include a lack of common standards for digital health technologies and limited human resources in many LMICs to manage the technology infrastructure and use the data this infrastructure can generate (WHO, 2010a). In this fragmented landscape, scaling of promising digital health solutions is often impeded by a lack of coordinated funding aligned with government priorities; limited regional leadership and peer support; and a lack of low-cost, easily reused, and adapted technologies such as those built with open source software. As several speakers emphasized throughout the workshop, developing digital health-focused PPPs based on government- and community-identified priorities can help connect the dots among the many stakeholders within the digital health landscape, foster coordination and integration, engage both public and private sector stakeholders in tackling existing challenges, and increase the potential for impact. To explore how the use of technology can facilitate progress toward globally recognized health priorities, including the SDGs, the Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) created an ad hoc committee to plan a workshop with the following objectives (see Box 1-1)2:

• Identify and explore the major challenges and opportunities for developing and implementing digital health strategies within the global, country, and local context. • Frame the case for cross-sector and cross-industry collaboration, engagement, and investment in digital health strategies. • Discuss how health and the health sector can drive other sectors to adopt digital technologies as a common platform. • Identify the ecosystem of actors necessary for successful digital health strategies, and country- and local-level solutions for moving forward.

2 The PPP Forum was launched in late 2013 with the objective to foster a collaborative community of multisectoral health and safety leaders to leverage the strengths of multiple sectors and disciplines to yield benefits for global health and safety. PPP Forum workshops are an opportunity to share lessons learned and promising approaches, and to discuss how to improve future efforts in areas of global health and safety promotion that have been prioritized by forum members.

4 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

BOX 1-1 Statement of Task

An ad-hoc committee will be appointed to plan a public workshop to explore the use of technology to advance global health, particularly how technology can facilitate progress toward globally recognized health priorities including the ambitious targets of the Sustainable Development Goals (SDGs). Focusing on opportunities for technologies—including products, systems, and services—to advance and accelerate global health priorities, the workshop will feature invited presentations and discussions to examine the following:

• Current efforts to increase investments in, development of, and access to global health technologies and technology-based interventions; • Decision making for when to use or develop technologies and what are appropriate technologies, including engaging governments and communities in prioritizing, designing, and evaluating global health technologies and technology-based interventions; • Learning from other sectors to better understand how to incentivize higher levels of participation for development and scaling of global health technologies and technology-based interventions, including how challenges have been managed; • Approaching cost-effectiveness assessments for global health technologies and technology-based interventions; • Addressing privacy, ethics, and security concerns with data collection and data sharing; • Ensuring technologies are accessible to those who need them the most, meaning “the last mile” populations; and • How policy and regulatory frameworks can function as enablers in the development and deployment of technologies.

The committee will develop the workshop agenda, select and invite speakers and discussants, and moderate the discussions. Experts will be drawn from the public and private sectors as well as academic institutions to allow for multilateral, evidence-based discussions. A summary of the presentations and discussions at the workshop will be prepared by a designated rapporteur in accordance with institutional guidelines.

To provide some additional context for the workshop, Aerts briefly described the findings of a study conducted by the Broadband Commis- sion for Sustainable Development’s digital health working group. The subsequent report (Broadband Commission for Sustainable Development, 2017), developed from case studies of eight countries at different stages of development or implementation of their digital health strategies, out- lined three key success factors. The first is the need for visionary and

INTRODUCTION 5

committed government leadership to formulate a strategy and secure sustainable funding for implementation. The second factor is to have effective governance mechanisms that engage stakeholders with clearly defined roles and help ensure efficient decision making on a national digital health strategy. The third key to success is a national ICT framework that facilitates alignment between the health and ICT sectors. Such alignment can promote connectivity and interoperability, help establish common standards, and enable appropriate policies and regulations for digital health. The study also found that the eight countries applied one of three different governance mechanisms for digital health: a health ministry mechanism, a government-wide digital agency mechanism, or a dedicated digital health agency mechanism. Concluding her remarks, Aerts posed four questions for the workshop participants to consider over the course of the day:

1. How can we make digital health into a transformative tool, one that improves health and increases equity and economic development? 2. How can we encourage innovation across the spectrum, with regard to systems, services, and partnerships? 3. How can digital technology be leveraged to address the most pressing global health challenges in a multidisciplinary manner? 4. What is needed to ensure we can proceed to scale?

ORGANIZATION OF THE PROCEEDINGS An independent planning committee organized this workshop in accordance with the procedures of the National Academies of Sciences, Engineering, and Medicine. (See Appendix B for the agenda.) This publication summarizes the workshop’s presentations and discussions, and it highlights important lessons, practical strategies, and opportunities for using digital technologies and developing partnerships to advance global health. The content of the proceedings is limited to what was presented and discussed at the workshop and does not constitute a full or exhaus- tive overview of the field. In accordance with the policies of the National Academies, the workshop did not attempt to establish any conclusions or recommendations, focusing instead on issues identified by the speakers and workshop participants. The workshop proceedings was prepared by designated rapporteurs as a factual summary of what occurred at the workshop.

Digital Health Within the Current Global Context

Highlights and Main Points Made by Individual Speakers and Participants • Preventing, diagnosing, reporting, and responding to disease are the standard approaches to reducing the costs of disease in terms of lives, disability-adjusted life years, and resources. Innovations in information and communication technologies (ICTs) can reduce those costs. (Bollinger) • While there are many pilot programs demonstrating that ICTs can lower costs and increase the effectiveness of disease responses, the challenge remains to integrate the many available technologies to maximize those effects and do so at scale. (Bollinger) • National digital health strategies can improve public health planning, prevention, and service delivery capacity, as well as break down silos across government agencies. (Gaudry- Perkins, Herbosa, Novillo Ortiz) • National digital health strategies enable scaling and harmo- nizing digital health as they aid in setting frameworks for data interoperability, harmonization, and to build the appropriate laws to govern digital health. (Gaudry-Perkins)

8 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

• Deploying digital technologies in the health care sector must include partnerships with those who can either complement those solutions or provide valuable insights from their experiences. (Gaudry-Perkins) • In the early days of digital health technologies, there were many ingenious mobile health (mHealth) and telehealth strategies, but no framework for coordinating these approaches in a way that would stimulate development. (Herbosa) • It is important to involve all possible stakeholders when planning to scale and to identify what will create value for each stakeholder. (Herbosa) • A lack of laws and a national framework for digital health will cause even the largest public–private partnerships to falter. (Gaudry-Perkins) • Generating evidence of effectiveness and return on investment will be the keys to creating sustaining funding streams for ICT solutions. (Gaudry-Perkins)

The workshop’s opening session introduced multisectoral perspectives on key themes and considerations in digital health. Ted Herbosa of the University of the Philippines, Florence Gaudry-Perkins of Digital Health Partnerships, David Novillo Ortiz from the Pan American Health Organization (PAHO), and Robert Bollinger of the Johns Hopkins Uni- versity School of Medicine discussed challenges and opportunities in developing and implementing digital health strategies, the role of different stakeholders, incentives and drivers to adopt digital technologies, and solutions to move forward. Bollinger set the stage for the discussion by describing the value of digital technology through a public health approach. In public health, regardless of a specific disease or condition, over time, inaction will lead to an increase in costs in terms of lives, disability-adjusted life years (DALYs), and resources. Public health interventions, or actions, focus on preventing, diagnosing, reporting, and/or responding to the disease or condition with the goal of reducing those costs (see Figure 2-1). Innova- tions in digital technology, whether infrastructure improvements, mobile health, point-of-need diagnostics, big data analytics, and others, when applied to public health interventions, can accelerate or magnify shifts in any of the associated cost curves (see Figure 2-2). As an example, Bollinger noted that GPS-linked, just-in-time allocation of resources could produce an earlier and more effective response to disease outbreaks. Bollinger noted there are many pilot programs demonstrating that digital technology innovations can, in fact, drive cost and time curves

DIGITAL HEALTH WITHIN THE CURRENT GLOBAL CONTEXT 9

FIGURE 2-1 The cascade of health interventions for any disease. NOTES: Graph illustrates general trends based on “representative data.” DALY = disability-adjusted life year. SOURCE: As presented by Robert Bollinger on May 11, 2017.

Figure 2-2

FIGURE 2-2 IT opportunities for health interventions for any disease. NOTES: Graph illustrates general trends based on “representative data.” DALY = disability-adjusted life year; GPS = global positioning system; JIT = just in time; mHealth = mobile health. SOURCE: As presented by Robert Bollinger on May 11, 2017.

10 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

down and increase the effectiveness of responding to disease. However, he suggested that the challenge is to align initiatives and stakeholders to maximize those effects and to do so at scale. “How do we create a value proposition for the public–private partnerships (PPPs) that are necessary to take these to scale?” Herbosa recounted how when he was deputy minister of health in the Philippines, there were many technology startups and digital health pilot programs in the country, but none were scaling and coordination was limited. In response, the country, with Herbosa in the lead, established an enterprise architecture for scaling and coordinating digital health initiatives through the National eHealth Strategic Framework and Plan. Gaudry-Perkins became familiar with the concept of the mobile revo- lution 7 years ago and learned of the rising penetration rates of mobile phones in Africa and other less-developed regions. She observed that while the technology field was already seizing the opportunities that were arising from the increasing availability of mobile phones across the globe, the health sector as a whole was largely unaware of this phenomenon. She has seen the situation change since then, and the health sector has woken up to the many opportunities mobile technology affords for improving how health care can be delivered. Novillo Ortiz explained that PAHO, and, more broadly, the World Health Organization (WHO), is convinced that national digital health strategies, such as the one Herbosa implemented in the Philippines, can lead to improved public health planning, prevention, and service delivery capacity. PAHO/WHO is supporting the development of guidelines for different health components of information and communication technology (ICT), such as telehealth, mHealth, and electronic health records (EHRs). PAHO/WHO’s approach, he explained, focuses on guiding countries in regard to the components of digital health strategies, and facilitating information and knowledge exchange among countries that are developing and implementing their own approaches. Bollinger asked Gaudry-Perkins for her perspective on the current state of the private sector’s engagement in digital health. The first thing to consider, said Gaudry-Perkins, is that the different actors that have a role to play in digital health vary in their maturity. For example, from her perspective, pharmaceutical companies began incorporating digital health technologies into their corporate strategies within the past 2 to 3 years; whereas, the health insurance field got involved a little later. She observes insurers making the same mistakes that other sectors made initially with digital health, which is to try to go forward without striking partnerships with others who can either complement their solutions or provide valuable insights from their experiences. Even within the technology sector, Gaudry-Perkins noted that most

DIGITAL HEALTH WITHIN THE CURRENT GLOBAL CONTEXT 11

ICT partners would not be able to deliver a single, holistic solution for scale. “You need connectivity (networks), data centers, mobile devices, software, platforms, the cloud, and on and on,” she said, with each component, in some cases, provided by separate technology companies. Hav- ing to work with multiple partners in both the private and public sector highlights a key challenge, added Bollinger. “They are all going to have their own value proposition, their own incentives and drivers, and understanding that ecosystem will be important,” he said. To illustrate that challenge, Herbosa noted that the private sector’s main driver is profit, while government’s objective is to provide a service, and marrying those two drivers is difficult. Furthermore, he added, while the private sector moves fast and embraces disruptive innovation, government is more resistant to change and often has to pass laws and develop infrastructure to implement new technology. He noted that in the early days of digital health technologies, there were plenty of ingenious mHealth and telehealth strategies, but no framework existed for coordinating these approaches in a way that would stimulate growth and a broader effect. In Herbosa’s experience, donors in middle-income countries, such as the Philippines, often support digital health initiatives that are prescrip- tive about how a new technology should be deployed. In many instances he has found that these requirements from donors do not meet what a country has determined are its needs or duplicate something a country is already developing on its own. He suggested that the development of national eHealth strategic frameworks is a means of informing the private sector and donors about each country’s specific needs. As an example, Herbosa recalled how a telecommunications company approached the Philippines about developing a technology-enabled approach to reduce the country’s high maternal mortality rate. The company offered the Phil- ippines a system that would connect primary care facilities with district hospitals and then funded a proof-of-concept study. However, the Uni- versity of the Philippines already had a project underway in partnership with the National Telehealth Center that connected universities with rural health units. The technology company has since taken its system and is marketing it in other countries where there is a need. As an example of how the Philippines is using ICT, Herbosa described an information technology (IT)-enabled syndromic surveillance system that it developed with WHO funding. This relatively simple system relies on texts sent to a central office describing the symptoms of people brought to an evacuation center. He explained that if the texts contained many cases of watery diarrhea, he would immediately order chlorine tablets and water filtration systems to the affected region to prevent an epidemic outbreak of cholera. Similarly, if the texts reported infection and fever, he

12 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

would send out a measles vaccination team. Another example is the geographical information system used to deploy international medical teams in the aftermath of Typhoon Haiyan in 2013. When the teams arrived, Herbosa said, they all wanted to go to Tacloban, which was the focus of reporting on CNN. However, he knew that there were seven islands heavily affected by Typhoon Haiyan and the geographic information system allowed him to distribute the teams where needed. The result was that major outbreaks of diseases such as cholera were prevented. These examples illuminate Bollinger’s point that digital technology can move the public health cost curves. Novillo Ortiz commented on the challenge of filling the gap between what a country needs and what the private sector has to offer. Chile and Brazil have taken the approach of issuing public, transparent solicitations for solutions that have engaged the private sector. Another solution has been to use the National eHealth Strategy Toolkit developed by WHO and the International Telecommunication Union (ITU) (WHO and ITU, 2012). He also commented on the importance of taking time to explain the concepts of digital health technologies to the various ministers and other senior government officials who may not know or understand the value of these technologies for improving the health of a nation’s citizens.

OPEN DISCUSSION As someone who has helped negotiate the United Nations’ Sustain- able Development Goals, Simon Bland from UNAIDS said he sees a huge opportunity for technology to extract more value from limited health care funds, but it will require there being enough trained health workers available to use these technologies. He noted that WHO reported in 2013 that there was a 17 million health worker deficit, and on the present trajectory that deficit would still be 14 million by 2030. His question to the members of the panel was whether they have seen a correlation of successful digital health strategies with health workforce strategies, and in particular, if they have seen digital health strategies used to enable community health workers. In his opinion, doing so would create more demand for these technologies, which would create more incentives for private-sector investment to their technologies. Gaudry-Perkins, addressing the shortage of health workers, noted that there is a successful program in India that has trained hundreds of thousands of community health workers, yet other countries are not following suit because this program has not generated enough evidence of a return on investment or a reduction in disease. Similarly, she said, a telemedicine program supported by the Novartis Foundation demonstrated that 38 percent of the medical problems in Ghana could be dealt with by

DIGITAL HEALTH WITHIN THE CURRENT GLOBAL CONTEXT 13

a single phone call, but again, this program has not spread because there is a demand for more proof of a return on investment. Continuing with the theme of human resources, Bollinger asked the panelists about the other human resources needed to support ICT for health, particularly at the provider, clinic, and hospital levels. Herbosa replied by describing his tour of the rural health units that his office provided with computers and training for the local primary health care workers. “What did I see? I saw a computer with a cloth covering it.” What was happening, he said, is that only the young nurses and doctors were using the computer. “The more senior health professionals are the resistant ones, and the people in government are even more resistant,” said Herbosa. He predicted, though, that there will come a time when the younger generation of health care workers hits a critical mass and these systems will be more widely used. In the same way, he said, the younger generation of citizens in general is driving the use of mobile technology and social media for health promotion. “Suddenly, social media has a window in terms of health care,” he said. Novillo Ortiz added that over- coming the lack of human resources prepared to work on digital health involves working with various ministries to change the medical curricu- lum so health workers are prepared to use health informatics. Herbosa noted ICT infrastructure can be a challenge for scaling any pilots in low- and middle-income countries (LMICs). In his country, for example, a pilot might show promising results, but scaling it to all 7,107 islands may not be feasible because some of the islands do not have remote technology infrastructure in place. The challenge becomes larger when trying to bring in the private sector in a transparent manner, given that many of the players offering health IT for a country such as his do not have experience working in an LMIC. What is important is to involve all possible stakeholders when planning to scale and to identify what it is that will create value for each stakeholder. “When you do that, you will be able to collaborate,” said Herbosa. “You will have a common goal and will be able to deliver.” On this point, Gaudry-Perkins commented that one issue she has come to appreciate over the past few years is that a lack of laws and a national framework for digital health will cause even the largest public–private partnerships to falter. A lack of the appropriate regulation for digital health can deter large digital health companies from investing in that country, as they may deem it too risky. She emphasized that getting the right government digital health systems or frameworks in place is an essential step to scaling digital health. A national digital health strategy that has a governance system which has broken the silo between the ministries of health and ICT can enable the private sector to have a one- stop shop in order to get involved. “Once you start getting all of your

14 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

cross-sectoral working groups in place within a national digital health strategy, that is when it can be very effective for private sector,” said Gaudry-Perkins. George Alleyne of the University of the West Indies asked the panelists who would pay for the development of technologies to support digital health. Gaudry-Perkins responded that answering that question is one of the challenges for sustainability and therefore scaling. For many years, philanthropy drove the adoption of digital health in LMICs and this has undoubtedly contributed to the great fragmentation today. As an example, she cited the situation in Mali, where there are 10 mobile maternal health projects, each financed by a different funder and none of which can communicate with one another or with the country’s health agency. In her opinion, the WHO-ITU National eHealth Strategy Toolkit will help avoid this type of fragmentation, though the cost of developing a national health strategy may be beyond the resources available to many LMICs. Rwanda, for example, committed $32 million over 5 years to developing its digital health strategy. The World Bank is financing a project in Gabon right now to implement a national digital health framework and the budget is more than $50 million over 5 years. Costs can include investments in ICT infrastructure development, hospital health management information systems (standards and interoperability), surveillance, Internet-enabled eHealth services, workforce development, policy and regulation, and community-level systems (Broadband Commission for Sustainable Development, 2017; World Bank, 2016). Gaudry-Perkins suggested what will help countries allocate the necessary funds will be studies such as the one Canada conducted that showed the country has realized a return on investment of $16 billion since 2007 (Broadband Commission for Sustainable Development, 2017). She believes that the “who pays” question will be in part resolved, at least from a government perspective, as these technologies and programs mature and generate evidence. The private sector is already developing business models for digital health technologies, and in her opinion, the insurance industry will eventually have a very important role to play in this respect once it realizes the benefits of digital health tools in disease prevention and better disease management. Consumers may also become a driving force, she added, because of the potential for time saved. Novillo Ortiz noted that in the Americas, private health care is a powerful force in terms of technology adoption and innovation and that private health care is starting to share the lessons of its experiences with the public sector. In Panama and Costa Rica, for example, the public and private health care sectors are working together. In the private sector, added Gaudry-Perkins, the shift to outcomes-based health care will drive the adoption of digital health technologies. In France, she noted, the

DIGITAL HEALTH WITHIN THE CURRENT GLOBAL CONTEXT 15

government has recently passed a law that moves one particular health intervention to an outcome-based system and is paying doctors to adopt telemedicine so they can follow their patients at home and avoid unnecessary hospitalizations. The reason this is happening, said Gaudry-Perkins, is that the government became convinced there was a positive return on investment. Based on her experiences in both government and industry, Gaudry- Perkins said a key is to get high-level executives from both the private and public sectors together at the beginning of such discussions and talk about shared value and how a PPP can be a win for both sides. Too often, she said, such discussions start with either a business division or only the corporate social responsibility unit who do not see the big picture of how such partnerships can benefit entire organizations, not just the units or divisions for which they are responsible. An unidentified participant added that too often, high-level officials have no knowledge about digital health, but when informed about it become quite interested in learning more. Elsy Dumit from PAHO asked the panelists if they had ideas on how to convince governments, particularly those in LMICs where investment funds are limited, to make needed investments in digital health when the payback may be 10 to 15 years in the future. Gaudry-Perkins responded that there are investments that have short-term returns, and even then it is important to keep reinforcing the political will of the champions for these projects. One approach for doing that, said Novillo Ortiz, is to keep reminding policy makers that digital health is about improving people’s lives. Gaudry-Perkins added that it is critical to break down the silos that currently exist between ministries of health, telecommunications, and whatever agency is in charge of digital initiatives. “A true national digital health strategy cannot happen unless you build governance and break the silos between these worlds,” she said. In her experience, accomplishing that task is the number one challenge to building sustainable support for digital health initiatives. Herbosa noted that there are many models for PPPs in physical infrastructure. What is needed, he said, are models for PPPs for social infrastructure, including health care. In that regard, the question should not be “Who pays for it, but who pays for what?” said Herbosa. “Everybody pays for it, but what is your share?” Benjamin Makai from Safaricom agreed that “who pays for what?” is the right question, and that often the answer is not a direct one. For example, his telecommunications company participates in health-related projects not necessarily for the money, but because it helps the people who are subscribers to the company’s services stay healthy, which ultimately contributes to the company’s bottom line. Herbosa added another example in which the Philippines’ Department

16 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

of Science and Technology realized it could take advantage of the same unused portion of the television spectrum that the education department was using to reach schools in areas without Internet connectivity to connect to primary health care centers. In that case, nobody had to pay for the development of Internet infrastructure in geographically isolated and disadvantaged regions in the Philippines. Alain Labrique from the Johns Hopkins University Global mHealth Initiative said there is an important shift occurring in which governments are creating the ecosystems in which programs can succeed when they go from pilot phase to spread and scale. He then noted the results of a landscape analysis of projects for frontline health workers that had scaled successfully (Agarwal et al., 2015). The one common factor spanning these programs, he said, was their simplicity. “Simple projects manage to reach scale when they do one or two things really well—and then complexity can be added,” said Labrique. Labrique asked Herbosa how he has worked to shift the culture of the health care system in the Philippines to act on data in real time and to train health care providers on how to integrate data into their daily decision making. Herbosa shared that most people in the health ministry still wait to make decisions based on official data that is often years old. With a background in disaster and trauma response, Herbosa said he is accustomed to actively acquiring and using data, but he is a rarity in government and the policy-making arena in the Philippines with regard to data use. He also commented that too often, policy makers not only make decisions based on old data but do so without going into the field and seeing what is happening in hospitals and clinics. Labrique replied that perhaps data use should become part of medical training and that policy makers should be given permission to make mistakes and to take actions based on current data. The problem with giving permission to bureaucrats to make mistakes, said Herbosa, is that they lose their jobs when they are wrong. The way to address that issue, he said, is to make data available to policy makers earlier to take some of the uncertainty out of their decision making. As a final comment, Herbosa said digital health has three goals: increase access to care, prevention, screening, and health promotion; involve the public and private sectors in creating an infrastructure that promotes creativity and disruptive or constructive innovation; and establish an ecosystem that is truthful and transparent. Realizing these three goals, he suggested, will help build support and sustainability for digital health among both high-level decision makers and among those who will use and benefit from digital health technologies.

Enabling a Multidisciplinary Approach to Health

Highlights and Main Points Made by Individual Speakers and Participants • Having a sufficient digital infrastructure in a country is a key to the ultimate adoption and scalability of a specific solution. (Esposito, Johnson) • Physicians do not want more data, but rather data they can trust, that they can act on as part of their normal workflow, and that provides feedback to let them know the outcomes from acting on the data. (Esposito, Johnson) • It is important to encourage data use to create incentives for change. (Esposito, Johnson) • Addressing the current health realities, particularly in low- and middle-income countries, requires broad-based partnerships that engage sectors beyond health and technology. (Aerts)

Ann Aerts emphasized that there is a unique opportunity for public– private sector collaboration for digital health. Stakeholders in the private sector are developing strategies to advance the concepts of connected living and digital lifestyles. Health has been recognized as a critical element in this space with significant potential for new investments. As noted by several

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workshop speakers within the private sector, both technology and health care companies are well positioned to bring their core competencies to bear in the development of digital health initiatives and broad strategies to apply digital technology to health. In the public sector, governments have a clear interest in improving population health and well-being. Despite the incentives for investments in digital health within the private and public sectors, a number of workshop speakers acknowledged that barriers to collaboration exist. Some of the barriers raised by workshop speakers include a lack of support and infrastructure that allows access and affordability to digital health technologies, as well as a lack of interoperability across systems to increase ease in usage and minimize inefficiency. The workshop’s second session, moderated by Aerts, focused on established multidisciplinary business models for digital health employed by technology and health care companies. The two panelists—Jennifer Esposito from Intel Corporation and Darrell Johnson from Medtronic— discussed multidisciplinary business models for digital health. This session also featured a World Café in which the workshop participants addressed a number of questions related to how digital technology can enable a multidisciplinary approach to health.

MULTIDISCIPLINARY BUSINESS MODELS FOR DIGITAL HEALTH Intel’s processors power many types of medical imaging equipment as well as the networks and clouds that process, transmit, and store electronic health data. Jennifer Esposito explained that this application of its technology drives the company’s interest in health. The Health and Life Sciences group she leads at Intel works to apply lessons from other industries to solutions for health care and to inform Intel’s future product development road map. Darrell Johnson explained that Medtronic’s interest in digital technology has been driven by the company’s shift to value-based health care, which focuses on selling outcomes rather than products. Selling outcomes requires data, and the company’s 70 years of experience in the health care arena has produced a trove of data on patient care. “We spend a lot of money generating this evidence, and we have great relationships with regulatory bodies and payers with regard to this evidence,” said Johnson. “This is in our wheel house to be able to use these data scientifically to figure out what an outcome should be.” His group’s work focuses on tapping into real-world databases to solve three problems:

1. How to embed clinical research into clinical practice as a means of changing how Medtronic brings products to the market;

ENABLING A MULTIDISCIPLINARY APPROACH TO HEALTH 19

2. How to use data to understand the performance of the company’s products in the clinic at any time; and 3. How to use data to create products with the largest possible effect on value-based health care.

Aerts asked Esposito and Johnson for examples of where a multidisciplinary business model has worked to develop and deploy a digital health solution. Esposito replied that her group’s work in low- and middle- income countries (LMICs) starts with assessing a country’s underlying digital technology infrastructure. Sufficient infrastructure, she said, is a key to the ultimate adoption and scalability of a specific solution. Johnson agreed that there needs to be a technology platform on which to build a digital health solution. In the case of data, that platform comprises the multiple databases that are likely to be present in a country, and solutions must be able to extract data from those multiple sources in a way that empowers quality decision making. One type of solution that will not work well, he noted, is one that generates more data for physicians. Physicians, he suggested, do not need more data, but rather they need data they can trust and act on as part of their normal workflow; they need data that provides feedback to let them know the outcomes from acting on the data. Aerts agreed that actionability and feedback are two essential features of data that will be useful to the clinician. Regarding how Intel decides to engage in a public–private partnership (PPP), Esposito said that a prime consideration is whether such a partnership might provide an opportunity to understand the unique challenges for a specific issue and how its technology can solve those problems, saying, “We are doing it from the perspective of learning more about how we can take those unique challenges in a specific industry and drive solutions across the ecosystem with a variety of different types of partners.” The other reason to get involved in such partnerships, she added, is when there are opportunities to harness untapped data in a way that brings new insights to health care and that can ultimately change the way health care practitioners do their jobs. Johnson said that Medtronic is involved in many PPPs and embraces them as a tool for transforming health care and facilitating the exchange of data between patients and providers. One of Medtronic’s priorities in digital health is figuring out how to standardize data formats so patients can access their clinical data and share them with other providers or entities of their choice. Esposito noted there are other sources of health-relevant data beyond clinical data, such as education level, wealth, and social services, that would be useful and shareable with policy makers. In particular, she noted the ease

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with which the current generation of young adults operates in a mobile, data-generating environment. “They are used to the idea of continuously collecting data about themselves on the devices they carry with them,” said Esposito. “How that data can contribute to an overall improvement in public health is interesting to think about in terms of government involvement for broader societal gain.” She noted that there has been more interest in LMICs about developing a universal data platform that would cut across all social programs, in part because there is often no legacy infrastructure that can get in the way of data sharing. In response to a question about how to use big data to help reduce waste in health care systems, Johnson said one key will be to use data to make costs and outcomes transparent, enabling policy makers to address problems in ways that are specific to the location and circumstances. It will also be important, though, to convince providers and patients to make better use of the data that are already available. As an example, Medtronic makes a remote monitoring system for implanted cardiovascular devices that has proven to produce better clinical and cost outcomes by means of getting data to physicians quickly. Nonetheless, utilization is less than 50 percent because there is no consequence for reimbursement for not using it. Esposito agreed with the idea that it is important to encourage data use to create incentives for change, and she added that the ability to access multiple forms of data and use them to address specific problems has the potential to change how care is delivered. “If you are able to have real- time clinical information and all of this other information that surrounds the patient, I think you may be delivering health care differently,” said Esposito. “Instead of a disease-based approach, you are tailoring your actions around everything that is going on with that patient.” Richard Guerrant from the University of Virginia said that one obsta- cle to using data to improve care is the need to conduct research to generate the guidelines that physicians would then use. Johnson agreed and credited a partnership with the U.S. Food and Drug Administration that provides access to real-time data networks and large data sets on outcomes to conduct the research needed to generate evidence-based guidelines at a small fraction of the cost of current clinical studies. Jessica Herzstein, a specialist in preventive medicine, commented that even when good guidelines are available, the medical community is often slow to follow them, and Johnson added that the comment he hears repeatedly from physicians is that they do not trust the data that goes into the guidelines. Alain Labrique added that the World Health Organization (WHO) has

ENABLING A MULTIDISCIPLINARY APPROACH TO HEALTH 21

embarked on a digital health guidelines development process,1 a formal mechanism to develop guidelines for digital interventions, such as text message reminders for drug adherence. Florence Gaudry-Perkins asked the two panelists if they could provide some examples of business models with payers that take advantage of digital health technologies. Esposito said Intel has a partner in Latin America for which it built a device that patients take home with them from the hospital. This device has multiple sensors that patients can use to capture important physiological data that are then transmitted to the provider. The device also provides educational materials and allows patients to connect to a nurse call center if they need immediate help when a reading from one of the sensors is over a certain threshold. The payer provides the device as a means of controlling the ongoing cost of care, and the business model is that the service provider does not get paid unless there are cost savings. Initial results have shown there is a positive return on investment associated with this device, and Esposito’s hope is that the provider will deploy the device more broadly in multiple countries. George Alleyne asked if there are any private companies that would devote the resources needed to solving the data compatibility issue and if such an effort would be the focus of a PPP. Johnson replied that there are large companies working on this issue using blockchain technology to create an open market to exchange private health care information, something that he predicts will revolutionize the medical information industry. With regard to data transparency, Labrique asked the panelists what they see as the path of “fighting back against decades of dysfunction and the status quo of hiding things in the obscurity of having no data?” Esposito replied that in her experience, visibility quickly causes the status quo to change. “We have seen that in many different projects where as soon as you make data visible to a decision maker, everybody suddenly mobilizes around it and changes their behavior much more quickly,” she said. As a final note, Esposito said that collecting electronic data does not have to be expensive and is not necessarily the province of the developed world, a statement with which Johnson agreed. “The technologies that work in today’s world are designed with simplicity, elegance, and simple usability,” said Johnson. As an example, Medtronic has a project in Ghana where mobile phones are used to monitor blood pressure and make pay- ments to physicians.

1 For more information on the WHO Guidelines for Digital Health Interventions, see http://www.who.int/reproductivehealth/topics/mhealth/digital-health-interventions/en (accessed November 7, 2017).

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WORLD CAFÉ DISCUSSIONS While the incentives for the technology and health sectors to invest in digital health were clearly defined by Esposito and Johnson, Aerts noted that the current health realities require broad-based approaches inclusive of additional sectors to address the underlying determinants. The health systems in LMICs in particular are not prepared to face the challenges arising with rapid urbanization, the increase in health inequalities that comes with urbanization, the continuing threat of existing infectious diseases and from emerging diseases, and the rising burden of chronic disease. Noncommunicable diseases such as hypertension, the number one killer in the world, are ubiquitous, but they affect LMICs disproportionately, with four out of five deaths from noncommunicable diseases occurring in those countries. The loss in economic development in LMICs from noncommunicable diseases is estimated at $47 trillion over the next 15 years. This situation, said Aerts, calls for innovation in the way health care and prevention are delivered and for bringing together multiple disciplines to address the enormity of the challenges in global health. As an example, the underlying causes of cardiovascular disease include exercise level, smoking, food habits, alcohol consumption, and exposure to air pol- lution. These determinants, she said, cannot be addressed by the health system alone. “We have to work together with partners from other sectors,” said Aerts. “Only then can we think about how to improve health care.” Toward that end, she noted that among the workshop participants were public- and private-sector experts in information technologies, transportation, food production, consumer goods, finance and insurance, and energy, and she encouraged the participants to have robust discussions during the World Café2 segment of the workshop while discussing these two questions:

• Digital health is a tool that could enable intersectoral collaboration for better health. In which of three of these sectors—government, food and beverage and consumer goods, research and education, financial and insurance, infrastructure and transport, and energy—should digital technology be leveraged to address the underlying determinants of health? For each of these three sectors, define the three most important lines of action.

2 During the World Café, workshop participants broke into small groups and were led through a collaborative dialogue process to share knowledge and ideas for action.

ENABLING A MULTIDISCIPLINARY APPROACH TO HEALTH 23

• When considering translation into action, what can the health care sector drive and what can the digital sector drive for other sectors to adopt digital technology as a common platform?

Reporting back from the World Café discussions, Gillian Christie from The Vitality Institute shared that several participants at her table described three groups that were important to using digital technologies to enable a multidisciplinary approach to health: finance and insurance, consumer goods not including food and beverage, and research and education. The first group is needed to address the behavioral determinants of using this technology, the second group would be instrumental in deploying new technologies, and the third group would generate a better understanding of how technology and the data from technology could be used to change behaviors. Several participants at this table agreed that there is good alignment between finance and insurance and consumer goods, given the role of the private sector in each of those sectors, and that health care costs and outcomes were the primary drivers for these sectors to engage in partnerships. The research and education sector would focus on translation and commercialization and how to tap into social networks and cultural empowerment to produce change. Herzstein, reporting from her table, said that several participants sin- gled out the food and beverage sector and said that its role was to inform and communicate about nutrition and its link to noncommunicable diseases and to address myths and develop trust around new technologies and foods. The information technology (IT) sector would focus on understanding nutritional content, developing a system for food labels, and helping the public understand what good science is and how to judge nutritional information. Another line of action this group decided on was how to involve the transport sector in helping rural and underserved areas access health care by developing mobile health units for delivering emergent and nonemergent care. The IT sector would play a role with technologies for matching health needs with available transportation options. The transport sector could also work on developing a centralized and integrated control function that would improve the efficiency of responding to disasters or a developing disruptive situation such as the emergence of disease. The IT sector would contribute by digitizing cities and translating complex data to simple data that could be used quickly for an urgent response to a disaster or developing disruptive situation. The transport and IT sectors could also work together to develop geographical information systems to match needs with resources and transport options to deliver those resources to where they are needed. A participant from an additional table shared that her group selected three important sectors: government, research and education, and insur-

24 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

ance and financial. This group decided that government’s most important actions were related to leadership, developing an effective governance mechanism, and creating a national information and communiation technology network to eliminate fragmentation and silos. The research and education sector should explore approaches for increasing the usefulness of collected data for providers and should focus on digital literacy and best practices in digital health. For the financial and insurance sector, this group suggested that it needs to use big data to identify the risk factors linked to the social determinants of health. This sector should also adopt a different perspective on return on investments and explore ways of using mobile money as an incentive for adopting and scaling digital health initiatives. With regard to how to translate these suggestions into action, this group decided that the health care sector should prioritize the key issues that it needs to address and work to harness big data to reduce inefficiencies in care while the digital sector should work to standardize data collection systems and use those data to model health outcomes. For its proposal to develop a different perspective about return on investment, this group proposed that the health care and financial and insurance sectors should adopt a transparent outcome-based purchasing and reimbursement mechanism that could be informed by the digital sector’s work on modeling health outcomes using big data. At the same time, the digital sector should improve the security of financial transactions in a way that would enable mobile money. The digital and financial sectors should also work toward standardizing regulations for mobile money among countries.

Country-Level Digital Health Strategies

Highlights and Main Points Made by Individual Speakers and Participants • The notion of using data to fight disease is starting to spread and take root in many low- and middle-income countries (LMICs). (Myrick) • So-called “teenager” technology companies can become willing partners in projects that grow organically, when becoming a partner is easy, and when they are asked to deliver their core competencies. (Myrick) • Collaboration is hard to do, takes time, and has to involve in-person meetings that build relationships. (Long) • Educating the stakeholders in the health ecosystem in LMICs is an important early step when attempting to get input from potential users on a digital health solution. (Oyedepo) • Establishing governance structures, building technical and intellectual capacity, and empowering government to ask fundamental questions can lead to sustainability. (Marcelo, Oyedepo) • When putting together partnerships, it is essential to acknowledge the role, value, and relevance of every partner. (Oyedepo)

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• Public–private partnerships can only be successful when government realizes that it must establish governance structures, architecture, and program management capabilities. (Marcelo) • By being more open ended and flexible in its program requirements, the donor community can help reduce the fragmentation in the digital health landscape. (Myrick)

While digital technology can improve health outcomes, particularly in low-resource settings, a fragmented landscape of actors and interests working to implement digital health solutions can lead to a lack of coordination, waste, and unrealized benefits. There can be an opportunity to build health solutions around market needs in a coordinated and integrated way if digital health strategies are aligned with the health priorities established by countries and communities. Starting with country- and community-led priorities can aid the private sector in developing digital health strategies that are responsive to the needs of patients and communities. Collaboration among the actors of the ecosystems for health and technology advances the opportunities for business and therefore impact. This workshop’s third session featured lessons learned from strategies based on country-level priorities, explored frequent barriers and challenges, and distilled critical success factors. The session began with a context-setting presentation by Neal Myrick from Tableau describing an organic partnership that developed to eliminate malaria in Zambia. Next, each of the other three panelists—Lesley-Anne Long from PATH,1 Olasupo Oyedepo from the Health Strategy and Delivery Foundation’s ICT4HEALTH project in Nigeria, and Alvin Marcelo of the Asia eHealth Information Network (AeHIN)—gave short presentations on the projects in which they are involved that aim to improve digital health coordination to meet country and community needs. Elaine Gibbons from PATH then moderated an open discussion with the panelists and workshop participants.

ENGAGING DIGITAL “TEENAGE” COMPANIES IN GLOBAL HEALTH Tableau, explained Neal Myrick, is a partner in a project that PATH has organized to outfit more than 1,200 community health workers in southern Zambia with mobile technology they can use to record data on the incidence of malaria and track the progress being made in Zambia’s

1 Lesley-Anne Long from Digital Square (hosted at PATH) as of September 2017.

COUNTRY-LEVEL DIGITAL HEALTH STRATEGIES 27

efforts to reduce the number of malaria cases in the country. Using con- ventional malaria control methods, the Zambian Ministry of Health, PATH, and other partners had achieved a marked reduction in malaria cases in southern Zambia, but getting to zero cases was proving to be a large challenge, in large part because 80 percent of individuals infected with the malaria parasite are asymptomatic. “When somebody does get sick, health officials see that person as a canary in a coal mine. If that person is sick, then in all likelihood there are a bunch of people back in the village who are carrying the parasite and do not even know it,” said Myrick. Today, when someone in Zambia’s Southern Province is diagnosed with malaria, community health workers go to the individual’s village and administer a test for the parasite to everyone in the village. They then treat everyone who tests positive for the parasite, even those who are asymptomatic, and help the villagers implement bed nets, one of the most effective methods for preventing mosquito-to-human transmission of the malaria parasite. Taking this approach and repeating it in neighboring villages, the goal is to create malaria-free zones and to use the data the community health workers collect to help decision makers at all levels best direct resources. Myrick noted this approach has cut the number of malaria cases in the Southern Province and the number of malaria deaths significantly over several rainy seasons (see Figure 4-1). The notion of using data to fight infectious disease is starting to spread and take root in other countries, including Vietnam, where Tableau is part- nering with PATH, the Vietnam Ministry of Health, and the U.S. Centers for Disease Control and Prevention (CDC) to implement an emergency operations center for disease surveillance. Tableau’s role, he explained, has been to provide software and training that enable the government to collect data remotely, have it transmitted into a central system, and then push an analysis based on those data back to the field in the form of interactive visualizations. Those visualizations show when and where infectious diseases are being diagnosed and help the Ministry of Health predict where infectious diseases, such as Zika, malaria, and yellow fever, are going to be diagnosed so it can mobilize resources early and prevent an outbreak from becoming a pandemic. Myrick and his colleagues at Tableau are excited about using public–private partnerships (PPPs) and various philanthropic, corporate, and government funding mechanisms to spread the models they have applied in Vietnam and Zambia to other countries. Recounting the story of how these partnerships with PATH came about, Myrick said that when PATH first approached him, he expected to be asked for money or use of the company’s business intelligence software. Instead, the PATH representative asked him if he would like to help eliminate malaria in Zambia. What PATH wanted was actual engagement

28 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

Confirmed nfections via eactive Case Detection Confirmed assive Cases in Health Facilities Confirmed assive Cases by CHs Clinical (unconfirmed) alaria

umber of alaria Cases

ar un Sep Dec ar un Sep Dec ar un Sep Dec ar un

FIGURE 4-1 Trends in malaria case reporting in southern Zambia over several rainy seasons. NOTE: CHW = clinical health worker. SOURCES: As presented by Neal Myrick on May 11, 2017. Figure developed by PATH for the Visualize No Malaria campaign, a partnership between PATH and the Tableau Foundation. Data source: Zambia Ministry of Health.

and partnership to realize this objective. “So we are not engaged just as a donor or a vendor, but as a partner in helping solve problems on the ground,” explained Myrick. As a fully engaged partner, Myrick learned that there were other technological needs that PATH had identified as essential for facilitating this project. One such need was the ability to translate District Health Information Software data into a format that Tableau could import for analysis. Myrick contacted the Tableau Zen Masters, a collection of some 25 customers and partners who are experts at using Tableau and data in general, and asked if they would be interested in helping eliminate malaria in Zambia. “Absolutely,” was the answer, but the Zen Masters soon realized they needed additional resources for this project, and they contacted other consulting firms to lend their expertise, pro bono, to the project. Eventually, as other technological issues arose, Myrick contacted other small companies who have also donated time and software to the project. One by one, technology companies started joining this 5-year campaign, which was launched with the website VisualizeNoMalaria.org. He noted

COUNTRY-LEVEL DIGITAL HEALTH STRATEGIES 29

that one of the messages he gave to the technology partners was that malaria cannot be cured in 1 year, and if they were going to commit to the project, they needed to do so for the full 5-year term to meet the Zambian government’s goal of having the country be malaria-free by 2021. Myrick pointed out that these “teenage” companies are not the titans of the information technology (IT) industry. Many of them, he explained, operate in cutthroat business environments with many competitors, and they have to put all of their energy toward competing in the marketplace to generate the revenues that enable them to survive. Nonetheless, these companies have become willing partners in this project. The reasons were many, including the fact that the partnerships grew organically, each company was asked to deliver core competencies, and the process of becoming a partner was easy. “There was no paperwork,” said Myrick. “It was not 6 months of negotiation over their engagement and indemnifica- tions. It was: ‘We need your technology, we need it now, can you do it?’ followed by yes and done.” Another key to success in the partnership in Zambia was that the Tableau Foundation’s grants are unrestricted, which encourages innovation and flexibility. In addition, PATH’s 10-year working relationship with the Zambian Ministry of Health meant there was on-the-ground expertise in both the local cultures and how the government worked. While the teenage technology companies provided the technology, PATH provided the expertise in how to assemble those technologies in an effective way to meet the needs of the government. “Having an implementer like PATH that can actually pull things together and design the right solution for Zambia is something I think that has led to the success of this project,” said Myrick.

PATH’S DIGITAL HEALTH INITIATIVE2 Lesley-Ann Long shared another technology-enabled initiative that PATH is leading to increase coordination and response in health emergencies. During the 2014–2015 Ebola outbreak in West Africa, more than 50 different technology platforms were developed and deployed to respond to different aspects of the crisis. Most of the organizations developing and deploying these platforms did so without involving the local governments or with much understanding of the context in which the platforms would operate, and as a result, the ministries of health had a hard time understanding what was happening in their countries and which data

2 Digital Square is a U.S. Agency for International Development (USAID) program designed and funded in partnership with the Bill & Melinda Gates Foundation (BMGF). PATH announced the program in September 2017 with more than 40 partners.

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they could trust, said Long. In addition, once the crisis was over and the organizations that had deployed these platforms departed, there was little expertise remaining regarding how to use these platforms, integrate the data they generated, and use the data to make informed decisions. Long noted that this is not an unusual occurrence for those who work on development projects, which is one reason why so many pilot projects developed during crises fail to persist or scale. The Digital Health Initiative is a U.S. Agency for International Devel- opment (USAID) program designed and funded in partnership with the Bill & Melinda Gates Foundation (BMGF). The initiative was launched to address the coordination problems in global digital heath projects and to support countries to create national-level, integrated digital health systems. At the time of the workshop, the initiative was beginning conversations about how it can support governments to create digital systems that donors can co-invest in and that technology and global health partners can get behind and support in a coordinated manner. Long explained that the initiative was created to take on four roles:

1. Advocating for national integrated digital health systems and the use of global goods (technologies, often open source, which can be reused, adapted, and scaled); 2. Coordinating the activities of the donors and technology community through the Digital Health & Interoperability Working Group and its 100+ members; 3. Coordinating smart investments in global goods, so that every dollar invested stretches further; and 4. Establishing an African Alliance of Digital Health Networks to build and support the development of the next generation of in- country, technology-savvy leaders who will be able to decide how investments will be made to best meet their countries’ needs.

Long then noted that the initiative’s role includes working with governments, the private sector, and others to promote greater collaboration and coordination around investments in digital health. “Collaboration is hard to do, and it takes a lot of time,” said Long, and “you cannot do it by Skype. You have to go to the country, and you have to meet people and build those relationships.” She added that few donors fund collaboration and convening activities and that with a mandate to do this kind of work, the initiative can act as a neutral broker that can bring the “usual global [development] players” together with technology companies, governments, and the people working locally in these countries to have the conversations needed to create effective partnerships.

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IMPLEMENTING A NATIONAL EHEALTH STRATEGY IN NIGERIA In 2013, the Nigerian Minister of State for Health looked at the national health landscape, and he was convinced that technology could be leveraged to impact health outcomes but was concerned by the abys- mally low return on investment given the huge amounts of money being put into technology in the health sector, said Olasupo Oyedepo. Working with the communication technology minister, the Minister of State for Health secured support from the Norwegian Aid Agency through the United Nations Foundation and created a process and project—tagged ICT4Saving One Million Lives—to, among other things, drive the development of a national eHealth strategy. Oyedepo recounted that the strategy development team ran into a number of problems. The first problem, which many low- and middle-income countries (LMICs) experience, is that any digital health strategy needs to be designed with the end users in mind, but the intended end users were not appropriately informed about digital health to provide useful input. Thanks to the flexibility of their donor, Oyedepo and his colleagues were able to take 3 months to focus on educating stakeholders about the digital health ecosystem. They also used the World Health Organization (WHO) and International Telecommuni- cation Union national strategy document as a guide and invested time strengthening and building the capacity of the digital health ecosystem. These efforts paid off, said Oyedepo, because the resulting conversations with potential partners in government, the private sector, international development organizations, and the health sector became more than just listening to presentations and taking notes. “We had individuals in the room who could drive a discussion about how digital [strategies] will really help optimize health,” said Oyedepo. The lesson here, he said, was “strengthen the capacity of the group you are working with and life becomes easier.” Instead of driving the conversation, his team’s major job was to keep people on track, document ideas, and help tease out the substance of those ideas. The vision of the resulting national health strategy is that by 2020, eHealth will help enable and deliver universal health coverage in Nigeria. Arriving at that vision, he recalled, involved many heated discussions. Some of the stakeholders wanted the focus to be on affordability, others on improving access to care and the quality of care, but in the end, everyone realized that all of these are attributes of universal health coverage. The purpose of Nigeria’s national digital health strategy was to put in place overarching guidance for the use of technology in health and to then strengthen the capacity of the necessary and appropriate government structures to govern the implementation of proven technologies

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throughout the nation. Today, Oyedepo and his colleagues are working to support the government’s efforts to create and strengthen those governance structures, build capacity, strengthen collaborations, and empower the government to be able to ask some fundamental questions before it makes digital health investments that best serve Nigeria’s needs and that can be sustainable when outside funding ends. One lesson he has learned over the course of these activities has been that when putting together partnerships, whether with donor organizations, governments, or the private sector, it is essential to acknowledge the role, value, and relevance of every partner. For example, there is nothing wrong with a private company wanting to make a profit or with government wanting to improve the lifestyle of its citizens. The key is to find the middle ground that reflects the values important to each partner. Find- ing that middle ground depends more on the people and organizations involved than the technology, and it requires building trust and a strong sense of collective ownership among the partners.

ASIA EHEALTH INFORMATION NETWORK AeHIN was born out of a conference in 2011 organized by WHO and USAID on health information systems interoperability, said Alvin Marcelo. At the end of the conference, everyone was in agreement that health information system interoperability did not exist even within Min- istries of Health. Three months later, he recounted, WHO hosted another conference, with similar attendees arriving at the same conclusions. He noted that the conferences delved deeply into the problems, but no clear solutions arose. Frustrated with the stagnant state of affairs, Marcelo pulled together a group of colleagues from Cambodia, Indonesia, Laos, Thailand, and Vietnam to work on common solutions to interoperability and to learn from each other’s experiences. With a small grant from WHO, Marcelo and six colleagues from as many countries created AeHIN and developed a 5-year plan to build the network. The network then received additional support from the Norwegian Agency for Development, USAID, and Canada’s International Development Research Centre to build a platform for developing solutions. After five annual meetings of the network, trusted relationships have developed that enabled members to help each other solve health information systems’ interoperability problems. He added that he appre- ciates that the development partners, government representatives, and private-sector vendors who attend the annual meetings focused their discussions on how they can assist countries in solving those problems. Marcelo noted that the organization’s focus has developed to working with countries to address various gaps that impede interoperability. One

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common gap is not having a governance mechanism that can guide the activities of the many stakeholders and their competing agendas. “Unless you have a framework, you can lose your way,” he said. As an example he shared how one could get lost amidst the complexity of computerizing 1,600 hospitals in the Philippines, let alone one, without a framework and governance mechanism to guide them. Other important gaps include not having people with the right capacities and skills to build the architecture laid out in the framework and not having standards in place to create an interoperable architecture. For a governance structure, the network has adopted the COBIT 5 framework developed by the Information Systems Audit and Control Association, and 22 people from network countries have become framework certified. Marcelo said that these individuals now have the con- fidence that they can manage the complexity involved in creating and managing an interoperable, nationwide eHealth information system. Regarding system architecture training, the network has adopted The Open Group Architecture Forum (TOGAF) certification framework, and there are now 12 certified enterprise architects in Asian ministries of health. He explained that those who passed were health professionals, not technical staff. Later, this group of architects reviewed and adopted the Open Health Information Exchange (OpenHIE) interoperability framework as one with just enough sophistication and complexity for LMICs to understand and implement, said Marcelo. Currently, the network is working on developing program management skills among network members, and the Malaysian Ministry of Health is offering a training program that includes planning, procurement, program evaluation, and monitoring. The network is also looking at the PRINCE2 (Projects In Controlled Environments) and PMP (Project Management Professional) frameworks for program management. Mar- celo noted that once network countries have developed capabilities in governance, architecture, and program management, they will be able to select among the many standards that exist for interoperability. Marcelo said PPPs can only develop and be successful when government realizes that it has to do its part, which is developing those capabilities. With a governance structure, architecture, and program management capabilities in place, private-sector companies can then come in with their technologies and data and create national health information systems that are interoperable. He noted, though, that governments already have relationships with companies in the private sector that have developed from technology acquisition programs outside of the health sector, and that these relationships can be important when the health ministry starts talking to vendors about purchasing technologies. In fact, the network holds a biweekly webinar during which ministries of health and national

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insurance agencies talk about how they were able to solve specific problems working with specific vendors, who when asked, are allowed to discuss the features that enabled a particular solution. “We decided it will be the ministry making the presentation and the private-sector vendor providing support to the ministry,” said Marcelo. “I think that is a good way to model public–private partnerships, where government shows leadership and the private sector shows support.” As a final comment, he said AeHIN is starting to work with countries in Africa and hopes to start a collaboration soon with Oyedepo’s group in Nigeria, which is also certifying people in COBIT 5.

POTENTIAL OPPORTUNITIES TO ACHIEVE SCALE When asked to comment on how Tableau perceives the business opportunities for applying its products and services to global health, Myrick noted that he runs the company’s social impact team, whose mission is to encourage the use of facts and analytical reasoning to solve the world’s problems. “I am lucky in that I do not have a quota, so I am not responsible for generating revenue or new customers, and I can legitimately go after our mission without the sort of inherent conflicts people perceive,” he explained. He and two colleagues currently work in 54 countries through partnerships with PATH and networks such as AeHIN. The attraction of working with AeHIN, said Myrick, is that he and his team could play their part in building data literacy and capacity, which has allowed Tableau’s work to scale. Similarly, he said, his team works with the corporate office of Feeding America and by doing so has a beneficial effect on the organization’s 200 food banks around the United States. In Zambia, the only condition of his team’s participation was that community health workers and doctors had to receive training. “We think that is a more long-term, sustainable way of expanding this use of data,” he said. Returning to the subject of how his work fits into Tableau’s business operations, he explained that in the Zambia project, for example, the idea was to demonstrate what he considered a risky approach and if it worked, it would provide a good story that would inspire others. “If they decide to scale and buy software from one of our competitors, that’s just part of the risk we take,” he said. He added that when people do use Tableau’s products, they are using them because they have impact. “When the use of our product scales, it scales because it is actually helping people make better decisions that help them achieve impact.” What that tells Tableau as a company, he added, is that if his team is successful on the social impact side, the company not only achieves its social impact mission, but it also

COUNTRY-LEVEL DIGITAL HEALTH STRATEGIES 35

creates the potential—not a guarantee—that there will be a demand for Tableau products at some point. In fact, said Myrick, innovations arising from the Zambia project are now turning into product features that will help all of Tableau’s customers. One innovation, for example, involved adding a texting feature that notifies a clinic director when the data he or she submits do not pass an automated data quality check. As a result, data quality improved by 30 percent in just 4 weeks. Tableau is now investing time in refining this system so it will benefit other customers, said Myrick. From a social impact perspective, this project has had the added benefit of creating what Myrick called a generation of data champions among government and nongovernmental organization workers. “In Zambia and most of our other projects, they are able to see how you can use data to help you do your job better in various ways, and that increases the impact,” said Myrick. “That turns them into data champions.” This belief in the power of data is reinforced in these projects because the data come back to the people who generate it, rather than going off to the ministry office or to the funder and never being seen again. In fact, he said, delivering data back to the people who generate it, in a way they can use it and benefit from it, seems to improve the quality of data automatically.

DISCUSSION Katherine Taylor from the University of Notre Dame asked Myrick to elaborate on the concept of the teenager companies and how they fit into these partnerships. Myrick replied that he thinks of most teenager technology companies as being in the pre-initial public offering stage, with anywhere from 1 to 5,000 employees, and a wealth of intellectual capital and products that can solve real problems. However, because of their size and their focus on competing in crowded markets, they do not have the time or resources to engage in the longer discussions needed to build relationships with governments and other large organizations. As an example, he cited the company Alteryx, whose specialty is data transformation. In this case, the company’s software takes District Health Information Software data, combines it with other data, and configures it into a format from which Tableau’s software can produce reports. “We called them for that specific purpose and they donated their software,” said Myrick. PATH then built its internal capacity to deploy Alteryx’s software. Similarly, Twilio provided 5 years of its messaging services to enable the innovation Myrick described earlier. In each instance, as well as with the other teenager technology company partners, the Tableau Foun- dation reached into its ecosystem to identify a company with a product

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to address a specific on-the-ground need that PATH identified, and then it invited the company to join the project. One by-product of this process is that Tableau, PATH, and the United Nations are exploring the idea of building a marketplace where smaller companies such as these, which do not have the resources of Microsoft, Oracle, SAP, and other technology titans to sell into the LMIC market, can provide their technology at some prenegotiated price that an LMIC can afford. The hope is that such a marketplace would not only enable small technology companies to engage in those markets and for the information technology people in those markets to access innovative products, but it would also make the procurement process more transparent and perhaps eliminate some of the corruption that often accompanies procurement processes. Alain Labrique asked Marcelo about his perspective on incentivizing the engagement of large health care provider systems that have no inherent incentive other than a legislative requirement to be interoperable with a government-led registry system when they can function independently. Marcelo replied that in a country such as the Philippines, which has a single-payer health insurance system, the reimbursement system acts as the carrot and stick. In the Philippines, the Philippine Health Insurance Corporation, in partnership with the Department of Health, developed a system that mandates providers to submit their data in a standard format in order to be reimbursed. Such a system, he added, also protects purchas- ers from being locked into a product that will not work with future products because of an interoperability issue. He acknowledged, though, that getting private-sector providers and insurers to comply with standards will be more difficult in countries that lack some legislative mandate. Marcelo shared that AeHIN had also developed a Convergence Work- shop, a multisector meeting led by the ministry of health, that includes development partners and private vendors. The workshop is structured to establish the leadership of the ministry of health and to encourage the evolution of partnerships that contribute to the ministry’s mission of creating a national health information system. AeHIN has held workshops in Bhutan, Indonesia, Myanmar, and Vietnam, with participants in the initial workshops participating in those held in other countries. The next workshop, he said, will be in Cambodia. When asked which types of organizations are working in Nigeria, Oyedepo replied that it is a mix of large multinational corporations, small startups, indigenous donor and development organizations, and international development organizations. The problem is not finding organizations that want to work in Nigeria, given its size and population, but that most of the aid that comes in to fund health and technology programs is

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designed to strengthen specific programs, not the national system. As a result, the national system is not resilient to shocks. “One thing that needs to be thought through by donors and development partners in or outside of the country, and even the government, is the need to make the application of technology systemic,” said Oyedepo. In some cases, he said, this will require, as Marcelo noted earlier, going back and creating frameworks and fixing existing systems before intro- ducing a new technology to a broken system. “The sad thing about technology is that, at best, it is an enabler, it optimizes whatever exists,” said Oyedepo. What needs to happen, he added, is for donors and partners to start thinking about how their particular projects fit into the larger context of developing a national system rather than demanding that programs meet certain milestones as quickly and efficiently as possible. A participant from John Snow, Inc., commented that collaboration is the way to go, but asked what success looks like for these networks given the 10- to 15-year time frame for their development. One way to do that, said Oyedepo, is to break a project into smaller deliverables and report on those in shorter time frames, which he says can lead to the donor renegotiating the project time frame. Also important, he said, is to involve the government at each step along the way to make sure a project continues to fit into the government’s larger objectives and priorities. Myrick said the problem is that the donor is not the customer—the customer is the country’s government and people that a project aims to help. This is why he favors the social business model because it compels the partnerships to treat the intended beneficiaries as the customer, not the people who provide the seed funding for a project. Marcelo added that the convergence workshops, by having donors be participants, reinforce the idea that all activities are designed to support the ministry of health and its goals and not necessarily the short-term goals of the funders or private-sector partners. Gibbons concluded the discussion by asking the participants to share why they are optimistic about the future, given the challenges to collaboration that were discussed during the panel and more widely during the workshop. Marcelo replied that he is optimistic because his program and Oyedepo’s are starting to work together to create an Asia–Africa governance exchange program to share best practices and elevate the discourse around eHealth. Oyedepo said his optimism stems from the information exchange that happens in true partnerships. Regular reporting leads to the partners encouraging one another. It also provides a sense that accountability is a good thing, something that then leads to a stronger sense of ownership, and thus a stronger reason to continue to collaborate. Long said her optimism comes from working with people like

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Marcelo, Myrick, and Oyedepo, and observing an evolving dialogue in digital health over the last few years that is focused on genuine collaboration. Myrick said that he is encouraged when he hears leaders such as Marcelo and Oyedepo talking about having ministers—and not technology vendors—leading conversations. He added that he is optimistic that the example that USAID and BMGF have set by supporting and promoting PATH’s digital health initiative to end fragmentation will prompt other funders to follow suit.

Push Versus Pull at the Community Level

Highlights and Main Points Made by Individual Speakers and Participants • Mobile social media can address the professional isolation that many nurses and community health workers experience, which can lead to high rates of attrition, and it can also promote formal and informal knowledge exchange among health care workers. (Pimmer, Waugaman) • The massive adoption of mobile social media occurring in low- and middle-income countries can be leveraged successfully only if the issues of digital professionalism, the economics of participation, and information quality are being addressed. (Pimmer) • Digitization of data can increase the speed at which data can be used in decision making, the accuracy of the data, the plurality of the actors engaged in data collection and management, the flow of information back to those who generated it, and the engagement of communities. (Waugaman) • Countries should conduct baseline surveys to identify the strengths and weaknesses of their digital infrastructures. (Fast, Waugaman)

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• While data and technology may address some information management challenges, they often create new ones due to deficits of trained data scientists and analysts and governance policies. (Fast) • Partnerships can increase the benefits of health information technology and decrease fragmentation of solutions. (Yelpaala) • The development of digital professionalism requires health care organizations to provide health workers and health professionals with training and systematic guidance on how to use social mobile media tools in a responsible way and to assess the effect of their social media activities. (Pimmer) • Organizations need to shift their thinking about who will be mining and consuming data. (Waugaman)

In digital health, public and private sectors have primarily relied on a “push” approach, in which the public and private sectors push technologies out to the communities and programs, to deliver health through technology-enabled initiatives. In contrast, “pull” programs rely on empowering communities to provide their input into the technologies they want and need to address their specific health-related challenges. Such community-driven pull approaches, which get buy-in from both sides from the start of a project, can increase the acceptance and adoption of innovation from both the system that is establishing technologies and the individuals using the technologies. Questions arise as to how communities can be empowered to take an active role in pull programs, what incentives are needed to create the pull from communities, and what role community health workers can play in promoting pull from their communities. Such an approach can benefit from documenting the outcomes of digital health initiatives in order to understand what is driving success or scale. This panel addressed these issues using examples of pull programs in the digital health space in low- and middle-income countries (LMICs). The panelists were Christoph Pimmer from the University of Applied Sciences and Arts, Northwestern Switzerland FHNW; Adele Waugaman from the U.S. Agency for International Development (USAID); Larissa Fast, Fulbright-Schuman Research Scholar at Uppsala University and the University of Manchester; and Kaakpema Yelpaala of access.mobile International. Robert Bollinger moderated the panel and the subsequent open discussion with the workshop participants.

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SOCIAL MOBILE MEDIA TO CONNECT, TRAIN, MANAGE, AND EMPOWER HEALTH WORKERS In his work, Christoph Pimmer has focused on the role that mobile social media, including social networking applications such as Facebook and instant messaging applications such as WhatsApp, can play in supporting health professionals in general and community health workers specifically (Pimmer and Tulenko, 2016). Social media platforms, he explained, fall on a spectrum between those applications for small and bounded groups, or closed user groups, such as WhatsApp, and applications that can tie together large, nearly boundary-free networks. A major difference between mobile instant messaging and social network sites is accessibility, where instant messaging apps are simple and, in the case of WhatsApp, enable the exchange of audio messages that make them particularly useful for people of lower literacy levels, while social networking applications are usually more complex and also require higher levels of digital literacy to use effectively. Pimmer noted that almost all of the projects he and his collaborators have implemented with nurses and health workers in Nigeria, South Africa, and Zambia use WhatsApp as the primary social media platform. Mobile social media can provide four key functions for health workers: social, knowledge-related, organizational, and political. The social dimension is centered around professional connectedness that, Pimmer noted, addresses professional isolation, which the World Health Orga- nization (WHO) has identified as an important cause of the attrition of community health workers and nurses (WHO, 2009, 2010b). One example of how social media can increase social and professional connectedness is a Facebook site created independently by a Nepalese doctor. Tens of thousands of users, including doctors, other health workers, medical students, and even patients from Nepal and across Asia exchange some 1,500 interactions per week via this Facebook page. The discussions have included sharing experiences, the discussion of professional identities, values, medical procedures, and answering medical questions (Pimmer et al., 2012). In recent, still unpublished work, Pimmer and collaborators found further associations between social media use and professional connectedness. The findings suggest that the informal and nonguided use of WhatsApp by Nigerian nursing students during their clinical placements in the field can be associated with lower levels of professional isolation and higher levels of professional social capital. In addition to connectedness, almost all mobile social media spaces promote forms of formal or informal knowledge exchange, said Pimmer. Informal knowledge exchange and learning is common, he said, in groups or teams of community health workers or nurses, and he has seen many

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examples of these health workers using mobile social media to support one another in problem solving and learning activities. Results from a recent survey study underpin the value of mobile instant messaging technologies, such as WhatsApp, to enable knowledge creation and sharing, collaborative problem solving, and supporting formal education and professional development across a wide range of global health settings. Social network sites are increasingly popular. Nurses in rural South Africa, for example, use a closed Facebook group, which they access via their mobile devices, to consult among themselves when facing difficult cases (Pimmer et al., 2014). There is also potential to successfully leverage social networking sites in formal education settings. Pimmer and his colleagues have used closed Facebook groups to teach and coach rural nurses and midwives (Pimmer et al., 2016a,b). He said:

Of course, social mobile media spaces are not better than specific learning platform in terms of their functional repertoire, but their distinguish- ing feature is accessibility, which means in many contexts these tools are already in the hands of health professionals.

Another advantage can be reduced technical support needs. He added that in a project in South Africa, his team observed that nurses were asking their children or their neighbors’ children for technical help with Facebook when needed and very little support from the project team was required. The organizational function of mobile social media can help manage and coordinate what is often a distributed and remote workforce. Recently, said Pimmer, he studied how rural community health workers in Malawi used WhatsApp groups to organize campaigns, meetings, and drug distribution efforts involving workers in widely dispersed communities (Pimmer et al., 2017). Such organizing efforts increased the speed at which the health workers would complete their tasks and projects. In much the same way, social mobile media can give health workers and the communities in which they work the opportunity to organize themselves across communities in remote regions, and by doing so, increase their ability to accumulate and exercise power. In one instance, some 1,500 emergency department staff members in Taiwan created a Facebook group to voice concerns about poor processes and other work-related problems in their facilities (Abdul et al., 2011). Within weeks, this group had trig- gered what Pimmer said was a “quite stunning, multipart dialogue with different stakeholders, including the health ministry and even the health minister.” Eventually, breaking down communicative and hierarchical boundaries via social media resulted in the initiation of a reorganization process which had not been possible before.

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In the digital health landscape, mobile social media can play a com- plementary role to the more traditional function that most digital health tools play today, which is to capture and process structured health data and transmit them to a central authority. Mobile social media, in contrast, offers opportunities for more flexible and less-structured communication, particularly among groups or networks of health workers. Given the massive adoption patterns of mobile social media that are already occurring among health professionals, health workers, and communities, these informal virtual communities and networks are likely to grow with important implications for improving care in LMICs. However, to fully leverage the potential of the emerging media landscape, it is important to address associated constraints and risks in a proactive manner, Pimmer said in closing. This involves the consideration of issues such as digital professionalism (e.g., learning how to protect a patient’s privacy), the economics of participation (avoid further excluding the most marginalized groups), information quality (i.e., spreading of rumors and false news), and regulation related to the spread and use of mobile social media in health care.

VALUE PROPOSITION FOR PULLING DATA FROM THE COMMUNITY Adele Waugaman’s role in the USAID Global Health Bureau has been to support the development of interoperable and scalable digital technologies to overcome some of the fragmentation and duplication of digital health systems that affect health care delivery in LMICs. As an example, she discussed the research she and colleague Larissa Fast conducted on how data and information flowed in West Africa during the 2014–2015 Ebola outbreak there and whether digital technologies made a difference in those flows (Fast and Waugaman, 2016). During the course of interviewing some 130 people representing 60 organizations, Waugaman said that she and Fast heard anecdotes reporting that it could take as long as 3 weeks to get Ebola case information from the field to the central government offices for inclusion in the weekly situation reports on the outbreak. However, when digitized from the point of collection, data and information could flow more quickly and efficiently—up to 38 times more quickly, and with 21 percent fewer errors, according to research by the Gobee Group (Fast and Waugaman, 2016). Digital technologies also increased the plurality of the actors engaged in data collection and management. “We saw examples of citizens and frontline health workers communicating directly with health ministries and nongovernmental organizations in ways that were not possible at scale without the digitization of data,” said Waugaman. In addition, they

44 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

saw an increase in the directionality of data and information flow so that information—along with acknowledgments and appreciation—could flow from health ministries back to the communities as well as horizon- tally among peer groups. With paper-based case records, she explained, data moved primarily one way out of the communities for aggregation and decision making, with little information flowing back to the communities about what was happening in neighboring districts, for example. Turning to specific examples, Waugaman discussed the mHero project, which was run by IntraHealth in close collaboration with the Liberian Ministry of Health and with support from USAID and other partners. This project was unusual, she said, in that it was successfully piloted during a crisis, which is not an optimal time to test new technology. In this case, however, the mHero technology was integrating two systems that were already at scale—the IRIS human resources information system and the RapidPRO SMS bulk text messaging program—and was able to knit them together in a way that enabled the Liberian health ministry to communicate directly with its remote and widely scattered workforce. Waugaman explained that during the outbreak, many health workers fell ill or were otherwise not reporting for duty, so the health ministry needed some way to understand who was available and what training level they had received. “Setting up direct, real-time communications between health workers and the ministry of health enabled them to do that,” said Waugaman. The success of this project, she noted, can be seen in the technology’s continued use today by the Liberian Ministry of Health, which has incorporated these two-way, digitized communications with its remote workforce into the national digital health strategy. Another example of pushing data out of the community was the Ebola Community Action Platform (ECAP), a project in which numerous nongovernmental organizations used digital data and information they collected on mobile phones about community knowledge, attitudes, and perceptions about Ebola. These data, said Waugaman, were critical for informing the social mobilization response that proved to play an essential role in stemming the spread of Ebola. This program, led by more than 800 social mobilizers, reached some 2 million people in more than 3,000 communities across Liberia by using phones with Open Data Kit software and the WhatsApp peer-to-peer group messaging app. ECAP aggregated the data coming from Liberia and made it publicly available so social mobilizers involved in the Ebola response could gain insights into how they could leverage current understanding of the outbreak to change behavior through better messaging. One of the benefits of the ECAP project was that it gave workers who were going into complex and, at times, dangerous environments a peer-to-peer messaging platform that they could use to keep in touch

PUSH VERSUS PULL AT THE COMMUNITY LEVEL 45

with and provide encouragement to others who were doing similar work. Waugaman said that many field workers reported that this peer support was critical, in some cases even more important than financial compensa- tion, in motivating them to continue to work in difficult conditions. She also heard reports that United Methodist Church clergy in West Africa, who used the WhatsApp mobile chat platform to communicate with one another prior to the Ebola outbreak, were using it to report on cases in their communities. In one instance, a clergy member in Sierra Leone saw that a woman likely infected with Ebola was being transferred to a clinic that would have been unprepared to treat her. He used WhatsApp to alert the right people so that the patient could be diverted to a properly resourced clinic. The use of digital technologies also increased accountability, said Waugaman. For example, in Guinea, the use of GPS-enabled smartphones to collect contact tracing data created an additional layer of transparency around where, specifically, data was collected. It also enabled managers to see where there were gaps in data that were coming in from the field in near real time, enabling them to identify possible problems and cor- rect them quickly. Finally, she said, the use of real-time data improved programming to make it more directly relevant in the field. The Dey Say Program in Liberia, run by a nongovernmental organization called Internews, used a combination of text messaging and non- digital media to learn what rumors were spreading in communities and then address those rumors. UNICEF created a short code phone number that it provided free of charge to hundreds of health workers, nongovernmental organizations, and volunteers on the ground throughout Liberia. The short code could be used to report, by text, rumors about Ebola in their communities. The program analyzed the rumors and provided cor- rected information to local broadcast journalists, who were able to host locally recognized and trusted experts to debunk rumors over the radio. These examples, said Waugaman, illustrate how digital technologies can help both pull data from and push data to communities and engage community members in public health initiatives. However, she cautioned, “This is not just an ‘add water’ type solution. There are a number of different supporting and corollary investments that need to be made to enable the effective integration of digital technologies.” To illustrate what some of those supporting investments can be, Fast described what the data situation was like at the beginning of the Ebola outbreak in Liberia. As Waugaman had mentioned, case information from health facilities were initially collected on paper. At one point in the outbreak, some 500 cases per week produced up to 5,000 pages of information that had to be digitized and updated per week. This helps to explain time delays in getting data from around the country to the health ministry.

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Once the data were aggregated, they were released in situation reports published on PDFs that were not machine readable, and therefore were not easily accessible for other purposes, such as publishing the data on dashboards, disease modeling, or forecasting. Another issue was that field workers collected data on a number of different platforms and sent the data to the ministry via multiple reporting streams that often ended up in different data silos. For most nongovernmental organization workers, Excel spreadsheets served as the primary mechanism for data collection, but some treatment centers had electronic data collection too. For the latter, that raised questions about how to keep and use digital data in a “hot” (or Ebola-contaminated) zone, as well as how to maintain and then decontaminate electronic equipment in a hot zone. Combining these variables with the lack of common standards and data-sharing protocols complicated the compilation and aggregation of data across systems and actors, said Fast. On top of that, there were inconsistencies in the terminology used to describe Ebola cases. For example definitions of the primary categories of suspected, probable, and confirmed cases differed across the affected countries, and in some cases, those definitions changed over the course of the epidemic. While not surprising given that the responses themselves were run by the national governments, it meant that aggregating across the countries became more difficult during the outbreak. Based on this experience, Fast and Waugaman came up with a set of recommendations that they encapsulated in a visual aid adapted with permission from the data use cycle created by PATH and its partner Vital Wave (see Figure 5-1). These recommendations, said Fast, echo many of the comments made throughout the day, such as the need for standards for coordinated investment in health infrastructure to support digital health, as well as economic and social development and investment in the physical infrastructure needed to extend digital connectivity. As an example of the latter, Fast showed a map comparing cell phone coverage for West Africa in 2014 and those regions suitable for zoonotic, or animal- borne, disease outbreaks. The map revealed that there was a complete lack of cell phone coverage in some areas most suitable for zoonotic disease outbreaks. Another mapping exercise comparing cell phone coverage and the location of health facilities in Liberia showed why health workers in some clinics were unable to report on the outbreak. In some cases, said Fast, the workers had connectivity, but lacked the funds to contact the national coordination centers. These and other analyses led Fast and Waugaman to recommend that countries should conduct baseline surveys to identify the strengths and weaknesses of their digital infrastructures. Other recommendations address some of the personnel and institutional needs, and Fast said that

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Power, connectivity, physical infrastructure INFRASTRUCTURE

USER Training, capacity, and workflows for ENVIRONMENT digital technologies Consideration of the cultural, physical, and psychological contexts Harmonized, standardized, WORKFORCE and systematic design for

data capture

Data I E

transformed M E Quality data

into information

D collection M

at all levels DATA B

PRODUCTION A

C G

K O

Data Use Cycle R L

O P Enabling policies, O Information E processes across P INFORMATION V consumption, Evidence- I S sectors analysis, and USE based T action INVESTMENT comprehension P A INSTITUTIONAL STRATEGY D CAPACITY Incentivized A Harmonized donor and skilled investments and decision making sustainable strategies

Interoperable data, Strategies and use of standards, preparedness and scalable platforms to POLICY & protocols for support digital health REGULATORY digital health and and emergency response emergency response ‘INFOSTRUCTURE’ & STANDARDS

FIGURE 5-1 Graphic illustration of recommendations to improve the use of digital information to advance global health. SOURCES: As presented by Adele Waugaman on May 10, 2017. Adapted with permission from the Data Use Cycle graphic created by PATH and Vital Wave (https://www. usaid.gov/sites/default/files/documents/15396/FightingEbolaWithInformation. pdf [accessed January 19, 2018]) for publication in Fighting Ebola with Information by Larissa Fast and Adele Waugaman, 2016.

one key lesson from the report was that personnel and institutional short- comings are often more difficult to address than technical ones. “Tech- nological solutions exist,” said Fast, noting that addressing institutional and workforce capacity, such as policies, processes, workflows, and data literacy take time to address. As a result, while data and technology may solve some problems, they often create new ones that arise from a lack of trained data scientists and analysts and governance policies.

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Fast noted that while technology enables the generation of an ever- increasing amount of data at an ever-increasing speed, there is still a lack of understanding about how cultural, social, and behavioral issues can either promote or prevent the use of data or even digital technologies. “It is a physical context issue, but also about social aspects and whether people trust the information source,” said Fast. Trusted messengers, she said, are crucial, as is the ability to collect data in both online and offline environments. In addition, while data visualization can help promote data use, having too many dashboards displaying information that does not respond to the specific needs of the intended users is not necessarily helpful, she said. The final set of recommendations from their study was to coordinate investments in digital health, as well as in the development of common standards on both technical aspects and content to enable data to be shared and compared.

BOTTOM-UP INNOVATION TO IMPROVE PATIENT ENGAGEMENT When Kaakpema Yelpaala, a public health practitioner who had worked in the Caribbean, East Africa, and Ghana, founded access.mobile in 2011, his goal was to address the challenge of sustaining impactful digital health solutions with a business model not reliant on funding cycles and trends of donors. He used private investments to build a digital health company that engages with communities and the private sector directly on a value basis for the benefit of patients. His approach was to listen, learn, and evolve. Whatever technology access.mobile would develop would be built from the ground up using human-centered design principles and tailored to market needs with essential functionality. This approach was informed by many years on the ground, repeatedly asking questions of potential users, understanding their needs, and continually improving the technology in response to those needs. One of the advantages of working with mobile and Web-based solutions is that they can be easily adjusted, expanded, and evolved, said Yelpaala. His team relies heavily on evidence-based solutions, user feedback and data, and their own personal experiences in the field. Bottom-up innovation, Yelpaala added, requires addressing a significant problem that users want fixed and to do so with the simplest product possible. Getting feedback from early adopters is important to the process, as is providing users with information and incentives to try and keep using the technology. Yelpaala noted that access.mobile is a growth-stage company that raised money from friends and family and then a Series A investment to fund its initial growth. Some 150 hospitals and clinics serving approxi-

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mately 2 million patients use its end-to-end patient engagement solutions and generate between 100,000 and 200,000 messages a month related to patient health concerns. At the time of the workshop, the company was in the process of increasing its reach to 400 facilities, with three out of the top four private hospitals in Kenya using his solution as well as private hospitals in Uganda and Tanzania, and was building partnerships with large companies and the teenager companies Neal Myrick discussed earlier. In Yelpaala’s opinion, the way for a small company such as his to engage in a public–private partnership is to first establish partnerships with bigger organizations to help overcome initial market challenges and credibility while remaining nimble to adapt and innovate to market needs until ready for scale. Among the challenges for developing and implementing digital health solutions in Africa, said Yelpaala, are the need to create the space for digital health, which is a new and evolving market in Africa, and the need to change the way people seek and use health care. It is also challenging, he said, to develop a business model for scaling in a market driven by foreign aid and nongovernmental organizations and in which there is limited capital available for growth. The lack of interoperability, connectivity, and readiness to adopt digital technologies are additional challenges. At the same time, he said, there are opportunities to push the digital frontier of health care in Africa. Partnerships, he said, can increase benefits and decrease fragmentation, and policy developments could enable governments to facilitate advances in the quality and value of health care. The awareness of digital health benefits is also increasing in Africa. Yelpaala noted in closing that there is no one-size-fits-all solution for every user in any ecosystem. His suggestion is to think about end users in clusters, to engage with and develop solutions for each cluster, and to be flexible in the solutions offered to the users.

DISCUSSION Robert Bollinger commented on the two models for leveraging information technologies that were presented. The first model, described by Fast, Pimmer, and Waugaman, was the more organic of the two in that it provides communities with mobile phones, social media tools (or using technologies which already exist), and support and lets the users develop or adopt applications. The second model, presented by Yelpaala, is a more structured approach for delivering information technologies to communities that relies more on finding ways to build in responses from the community and optimizing delivery. Given those two models, he asked the panelists for their thoughts on how much of this work should be

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organic versus structured and strategically incentivized. In particular, he explained, he was thinking about community health workers, who are used to going out and getting what they need and therefore might be more amenable to an organic approach, but who could benefit from strategic incentives in the form of pay-for-performance or professional development, for example. Pimmer replied that community health workers need support, but unfortunately, they are perhaps the last members of the health care ecosystem to be given access to technology and the associated support systems. Nevertheless, he added, the deployment of digital media and espe- cially of mobile instant messaging is gaining momentum, and it will be in the hands of many more community health workers in the near future. The first challenge then, he said, is that the general social mobile media apps may be too generic for some forms of usage by community health workers, and would need to be complemented by special apps, which are more complicated to implement and that is where the organic evolution of these technologies will need support. However, a great deal of basic communication functions can be already realized with the help of openly available and widely used tools. To foster the bottom-up adoption, his approach has been to go into communities and learn about innovative practices that communities and health workers are developing and then help them to spread those innovations to other communities. However, he commented, given the risks and challenges associated with the current adoption patterns of mobile social media, health workers, health professionals, and health care organizations do require more systematic guidance on how to use social media tools in a responsible way aligned with ethical guidelines and to assess the effect of their social media activities. In thinking about how to further empower community health workers with information technologies, Waugaman said that there needs to be a shift in the way organizations think about who will be mining and consuming data. In most cases, health care organizations and government ministries are used to being the ultimate authorities on data, but they will need to figure out ways of sharing data effectively with the sources of the data to better empower frontline health workers and other health care providers. This shift in mindset becomes easier when moving from a paper-based data reporting system to one where data are recorded, transmitted, and analyzed in digital form—but it still needs to occur, and it will take time. Bollinger added how important that culture shift is given that the next Ebola epidemic will not be detected initially by researchers from a U.S. university, but by community workers. “Community health workers have to be incentivized not just to wait for a question, but to actually contribute to this system,” he said. Bollinger remarked that the LMIC setting, with fewer legacy systems,

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offers the opportunity to try new things, particularly with regard to delivering care in a disseminated manner, that is, out from centralized facilities and into local communities. He asked the panelists for recommendations on how to better leverage the community-based care model and technology to better manage both disease outbreaks and chronic care, both in the setting of underserved populations and back into the more traditional setting of Western medicine. Yelpaala replied that solutions can come back into the Western context, but it will require the right partners to translate solution approaches from one market context to another. Fast agreed that context is crucial, and Pimmer added that the development of digital professionalism will have to be a part of any effort to make better use of community health workers regardless of the setting. Waugaman, with the final comment, said that large donor organizations and nongovernmental organizations will need to learn to listen to a larger audience that is communicating in new ways and tie that back to the customer through adaptive programming.

Tapping into Grassroots Initiatives and Entrepreneurs

Highlights and Main Points Made by Individual Speaker • Africa is projected to have a larger workforce than any single country by 2035, and if that workforce is productive it will have a positive effect on the global landscape, but the world will have a problem if that workforce is a liability. (Oranye) • African innovators are doing impressive things in their local communities, but for the most part they are not connecting with one another to produce bigger impacts. (Oranye) • Funding is less of an issue for African innovators than is having access to opportunities and growth markets and finding partners with bigger footprints across the continent. (Oranye) • It is imperative that innovators in the health sector have conversations with those in the technology, telecommunications, and finance sectors to see how their innovations can fit together and produce a sum that is bigger than its parts. (Oranye) • A conversation is needed on how to bring those workers displaced by technology back into the workforce. (Oranye) • African innovators are fixing African problems in an African way, and funders need to respect that when deciding to support projects. (Oranye)

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• One key to continuing the promising economic momentum occurring in Africa is to promote African entrepreneurs and innovators and introduce them to the rest of the world. (Oranye)

The workshop’s final session focused on the importance and practice of cultivating an environment in which grassroots entrepreneurs and initiatives are contributing to the global digital landscape. The session began with a conversation between Nnamdi Oranye, an independent media contributor and author who has written about the power of technology and innovation to change the lives of Africans, and Anna Thompson-Quaye from access.mobile International. The session ended with an open discussion with the workshop participants. Thompson-Quaye began the conversation by asking Oranye to discuss the role of African innovation, both within the health sector and more globally. Oranye began his answer by noting that Africa is projected to have a larger workforce than that of any other nation by 2035 (Fine et al., 2012). If that workforce is productive, he said, it will have a positive effect on the global landscape, but if it is a liability, then the world has a problem. His mission over the past 5 years has been to chronicle the lives of innovators changing the landscape in the health and other sectors of the economy as a means of highlighting the enormous potential of African workers and bring them together with partners who can help them grow. When asked to address some of the trends in the innovation space in Africa that the rest of the world should pay attention to, Oranye said that African innovators are doing impressive things in their local communities, but for the most part they are not connecting with one another to produce bigger impacts. As an example, Vula Mobile, a small company in South Africa, has an app that makes it easy to refer patients to special- ists. The idea for this app came about because of an ophthalmologist’s struggle with traveling to rural villages to identify patients who needed cataract surgery. The problem is, when someone travels to the city to have cataract surgery, he or she may not have the cash on hand to pay for the procedure. If he or she had access to a new form of insurance developed by MicroEnsure, an entrepreneur in Kenya, that would not be a problem, and an app called Sproxil, developed by entrepreneurs in Ghana, would help him or her make sure that the drugs he or she has to take are not counterfeit. The problem, said Oranye, is that someone has to step up and put these together to create an ecosystem. “When we are thinking about funding or talking about pilots and projects, the conversation should be about how we put these innovators together because they exist, and they

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are doing great work,” he said. The important question to ask, he said, is how to support these entrepreneurs to help them scale their innovations. In terms of the challenges that these innovators face, Oranye said he was surprised that funding to scale was not that big of a challenge. In talking to innovators across the continent, he learned that funding is available, both from funding organizations and private equity funds. The real challenge, he said, is getting access to opportunities and growth markets, and the best opportunity for getting that access is by finding partners with a bigger footprint across the continent or to work with an organization such as PATH that can help make connections with suitable partners. He noted that Silicon Valley has become interested in Africa and in finding partners who have promising technologies and need help with scaling. More importantly, these companies appear to have figured out how to scale across Africa. As an example, he described how he can use the Uber app to order a ride whether he is in Johannesburg or Nairobi. On the other hand, a company called Fyodor has developed a rapid malaria test that can be used at home, but the company has no way of distributing it across Africa. “But if you had Amazon as a partner, as an example, distributing the product, that solution exists today,” he said. “The conversation I would like to hear when it comes to innovation is about distribution, how it affects innovators, and how we can help them scale.” Toward that end, cross-sector and cross-regional partnerships are “absolutely essential,” said Oranye. He said it is imperative that innovators in the health sector have conversations with those in the technology, telecommunications, and finance sectors to understand how their innovations can fit together and produce a sum that is bigger than its parts. “Those conversations, for me, need to start now as opposed to down the track,” said Oranye. To enable those conversations, he said he would like to see more cross-sector conferences in Africa and more innovators at workshops such as this one. One possible venue for such conversations, he suggested, would be a conference exploring how innovators and health officials in Nigeria worked together at the time of the Ebola outbreak in West Africa to keep the number of cases there to a handful. In her final question, Thompson-Quaye asked Oranye if there is a “dark side” to innovation. The answer, said Oranye, is that innovation can displace other industries and disrupt an entire ecosystem. As an example, he cited an app that was developed to pay for parking, but in South Africa there are people employed at the parking station to collect fees and make change. What happens, then, is that person, who is prob- ably earning money to feed four or five other people, loses his or her job. The conversation that has to take place, he said, is how to bring those who are displaced by technology into the fold. Africa, he said, has a fragile economy that is not strong enough to have too many people displaced by

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technology, so it is essential to bring those whose jobs are disrupted by technology into the workforce in other ways. Another potential disruptive outcome from innovation in the health sector, said Robert Bollinger, is the development of a private health care industry, something that has taken place in India over the past three to four decades. He asked Oranye if he sees any negative effects of private- sector opportunities, such as the ones being developed by companies such as access.mobile, becoming increasingly productive and valued. Oranye replied that in his opinion, that would be a great thing, in part because it might lead to the formation of public–private partnerships in health care that would in turn create an infrastructure that currently does not exist. Kaakpema Yelpaala asked Oranye for his perspective on innovators being crowded out of the market by foreign aid. While admitting that he is not an expert on foreign aid, Oranye said the real problem is that foreign aid organizations and private donors do not know about the innovators on the continent, and if they did, they would likely be interested in part- nering with these innovators. Toward that end, Oranye is developing a heat map of the innovators in the health sector and supportive services space. He is also trying to change the way foreign aid works with innovators, which typically involves coming in with a preconceived solution that might work as opposed to presenting a problem and letting innovators present potential solutions. He noted that African innovators in Africa are fixing African problems in an African way. “What needs to happen now is when aid comes in, it is to support that to scale,” said Oranye. When asked if he was optimistic about the future of Africa, he said he has seen enough innovators doing impressive work to see a bright future for the continent, and he believes that Africans are moving past a needs-based focus to one that is more forward thinking. One key to continuing the momentum that is occurring, he said, is to promote African entrepreneurs and innovators and introduce them to the rest of the world.

Final Thoughts

To conclude the workshop, Elaine Gibbons presented the key messages from the day. Gibbons said she heard clearly that government has to be the driver of public–private partnerships and that trust is critically important for the process of building guidelines and structure. She said she was struck by the optimism expressed that the current generation of innovators will be able to overcome many of the challenges identified during the workshop. Another important point for her was the importance of focusing on outcomes rather than on selling particular products, which she thought should be the subject of further discussion. Additional discussion is also needed, she said, on who pays for what and on the willingness and ability to pay for innovations. Gibbons said the importance of data and building a data culture was clearly stated at the workshop, as were the promising opportunities for using social media to better involve citizens in health care and to provide peer-to-peer support, particularly for nurses and community health workers who often work in difficult and isolated conditions. Her final comment was on the promising trends in innovation and the importance of creating ecosystems of innovators that can scale solutions rather than reinventing them in every community or country.

Appendix A

References

Abdul, S. S., C. W. Lin, J. Scholl, L. Fernandez-Luque, W. S. Jian, M. H. Hsu, D. M. Liou, and Y. C. Li. 2011. Facebook use leads to health-care reform in Taiwan. The Lancet 377(9783):2083–2084. Agarwal, S., H. B. Perry, L. A. Long, and A. B. Labrique. 2015. Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: Systematic review. Tropical Medicine and International Health 20(8):1003–1014. Broadband Commission for Sustainable Development. 2017. Digital health: A call for government leadership and cooperation between ICT and health. Geneva, Switzerland: Broadband Commission for Sustainable Development. http://www.broadbandcommission.org/ Documents/publications/WorkingGroupHealthReport-2017.pdf (accessed October 4, 2017). Canada Health Infoway. 2016. Report on digital health: The economics of digital health. https:// www.infoway-inforoute.ca/en/component/edocman/2821-infographic-report-on- digital-health-the-economics-of-digital-health/view-document?Itemid=0 (accessed July 17, 2017). Fast, L., and A. Waugaman. 2016. Fighting Ebola with information: Learning from data and information flows in the West Africa Ebola response. Washington, DC: U.S. Agency for Interna- tional Development. https://www.usaid.gov/sites/default/files/documents/15396/ FightingEbolaWithInformation.pdf (accessed September 21, 2017). FDA (U.S. Food and Drug Administration). 2017. Digital health. https://www.fda.gov/ medicaldevices/digitalhealth (accessed October 4, 2017). Fine, D., A. van Wamelen, S. Lund, A. Cabral, M. Taoufiki, N. Dörr, A. Leke, C. Roxburgh, J. Schubert, and P. Cook. 2012. Africa at work: Job creation and inclusive growth. Washington, DC: McKinsey Global Institute. Howitt, P., A. Darzi, G. Z. Yang, H. Ashrafian, R. Atun, J. Barlow, A. Blakemore, A. Bull, J. Car, L. Conteh, G. S. Cooke, N. Ford, S. Gregson, K. Kerr, D. King, M. Kulendran, R. A. Malkin, A. Majeed, S. Matlin, R. Merrifield, H. A. Penfold, S. D. Reid, P. C. Smith, M. M. Stevens, M. R. Templeton, C. Vincent, and E. Wilson. 2012. Technologies for global health. The Lancet 380(9840):507–535.

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Pimmer, C. 2015. Using Whatsapp groups to support community health workers: Preliminary insights from a pilot study in rural Malawi (interim report). Aargaul, Switzerland: University of Applied Sciences and Arts Northwestern Switzerland. Pimmer, C., and K. Tulenko. 2016. The convergence of mobile and social media: Affordances and constraints of mobile networked communication for health workers in low- and middle-income countries. Mobile Media & Communication 4(2):252–269. Pimmer, C., S. Linxen, and U. Gröhbiel. 2012. Facebook as a learning tool? A case study on the appropriation of social network sites from mobile phones in developing countries. British Journal of Educational Technology 43(5):726–738. Pimmer, C., P. Brysiewicz, S. Linxen, F. Walters, J. Chipps, and U. Gröhbiel. 2014. Informal mobile learning in nurse education and practice in remote areas—a case study from rural South Africa. Nurse Education Today 34(11):1398–1404. Pimmer, C., J. Chipps, P. Brysiewicz, F. Walters, S. Linxen, and U. Gröhbiel. 2016a. Supervi- sion on social media. Use and perception of Facebook as a research education tool in disadvantaged areas. International Review of Research. Open and Distributed Learning 17(5):200–214. Pimmer, C., J. Chipps, P. Brysiewicz, F. Walters, S. Linxen, and U. Gröhbiel. 2016b. Facebook for supervision? Research education shaped by the structural properties of a social media space. Technology, Pedagogy and Education 26(5):517–528. Pimmer, C., S. Mhango, A. Mzumara, and F. Mbvundula. 2017. Mobile Instant Messaging for rural community health workers. A case from Malawi. Global Health Action 10(1). WHO (World Health Organization). 2009. Increasing access to health workers in remote and rural areas through improved retention. Geneva, Switzerland: World Health Organization. WHO. 2010a. Landscape analysis of barriers to developing or adapting technologies for global health purposes. Geneva, Switzerland: World Health Organization. http://apps.who.int/iris/ bitstream/10665/70543/1/WHO_HSS_EHT_DIM_10.13_eng.pdf (accessed October 4, 2017). WHO. 2010b. Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations. Geneva, Switzerland: World Health Organization. http://www.who.int/hrh/retention/guidelines/en/index.html (accessed November 7, 2017). WHO and ITU (World Health Organization and International Telecommunication Union). 2012. National ehealth strategy toolkit. Geneva, Switzerland: World Health Organization.

Appendix B

Workshop Agenda

Forum on Public–Private Partnerships for Global Health and Safety Using Technology to Advance Global Health—A Workshop May 11, 2017 1777 F Street, NW, Washington, DC

The Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) fosters a collaborative community of multisectoral leaders from business, government, foundations, humanitarian and professional organizations, academia, and civil society to leverage the strengths of multiple sectors and disciplines to yield benefits for global health and safety. The PPP Forum is premised on the understanding that partnerships among these stakeholders can facilitate dialogue and knowledge exchange; use technological and process efficiencies; promote innovation; and synergistically advance humanitarian, international development, and global health interests. The National Academies of Sciences, Engineering, and Medicine provide a neutral evidence-based platform through which the PPP Forum is convened. This public workshop was planned by an ad hoc expert committee. The intended audience is the PPP Forum members and the organizations they represent, stakeholders from the information and communications technology sector, other public and private entities that have participated in or are considering collaboration across sectors to further global health and safety, and academics and researchers across multiple disciplines who are focused on understanding the value proposition and impact of various models of public–private partnerships (PPPs) to improve global health through the use of digital technology.

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WORKSHOP OBJECTIVES • Identify and explore the major challenges and opportunities for developing and implementing digital health strategies within the global, country, and local context. • Frame the case for cross-sector and cross-industry collaboration, engagement, and investment in digital health strategies. • Discuss how health and the health sector can drive other sectors to adopt digital technologies as a common platform. • Identify the ecosystem of actors necessary for successful digital health strategies, and country- and local-level solutions for moving forward.

WORKSHOP CONTEXT Current global health priorities, such as the targets of the United Nations Sustainable Development Goals (SDGs), are ambitious. Setting an agenda for the next 15 years, targets have been established to drastically reduce maternal mortality, as well as premature mortality, from noncommunicable diseases. Targets call for ending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases, among others, as well as achieving universal health coverage and ensuring universal access to sexual and reproductive health care services. While vast improvements have been made in global health in the past decades, the health challenges that weigh disproportionately on low- and middle-income countries (LMICs) continue to stand as a barrier to achieving poverty reduction and economic prosperity as intended by the SDGs. Meeting these targets, particularly reaching the last mile to achieve eradication or 100 percent population coverage, calls for innovative approaches. In this regard the global community has recognized the value of digital technology as a transformational tool to push forward the SDGs. Technology can help build on the interconnection among the goals, realize multiple benefits, and avoid barriers and conflicts on the path toward reaching the SDGs. Digital solutions can increase progress toward better health in LMICs through speed and reach, while increasing access to goods and services in a more people-centric, affordable, and sustainable way. Digital solutions that contribute to the social, economic, and environmental dimensions of sustainable development can provide attractive business opportunities. The information and communication technology sector, in particular, has existing stakes in the digital world and has shown increasing interest in the broader concept of a more connected digital lifestyle, of which health is a vital factor. The prospect of the value creation for investing in both digital ventures, as well as health improvement, creates an incentive for

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multisectoral involvement with both the public and private sectors finding value in developing partnerships with a digital health focus. PPPs promote a multidisciplinary approach to developing solutions, which is ultimately beneficial to all partners and the countries in which they operate. The digital health field has been growing over the last decade, and now includes categories such as mobile health (mHealth), health information technology (IT), information and communication technology (ICT), wearable devices, telehealth, and telemedicine. Applications for digital health are being used to reduce inefficiencies, improve access, reduce costs, increase quality, and personalize care. However, despite the growth of the digital health sector, digital health’s potential is not often being realized in LMICs because of an existing fragmented landscape in which multiple public and private actors and agencies with varied technologies and interests are working separately and with overlap. In this fragmented landscape, scaling of promising digital health solutions is often impeded by a lack of coordinated funding that is aligned with government priorities, limited regional leadership and peer support, and a lack of support and availability of open source technologies that could be reused or adapted. Developing digital health-focused PPPs based on government- and community-identified priorities can help connect the dots among the many stakeholders within the digital health landscape, foster coordination and integration, engage both public- and private-sector stakeholders in tackling existing challenges, and increase the potential for impact.

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AGENDA 8:00 am Registration

8:30–9:00 am Welcome Clarion Johnson, Co-Chair, Forum on Public–Private Partnerships for Global Health and Safety; Consultant, ExxonMobil

Introduction to the Workshop from the Planning Committee Co-Chairs Ann Aerts, Novartis Foundation Elaine Gibbons, PATH

I. Digital Health Within the Current Global Context The session will introduce multisectoral perspectives on key themes and considerations in digital health, including challenges and opportunities in the development and implementation of digital health strategies, engagement and collaboration between different stakeholders, incentives and drivers to adopt digital technologies, and solutions to move forward.

Facilitator: Bob Bollinger, Johns Hopkins University

9:00–10:30 am Opening Dialogue Ted Herbosa, University of the Philippines Florence Gaudry-Perkins, Digital Health Partnerships David Novillo Ortiz, Pan American Health Organization/World Health Organization

10:30–10:45 am BREAK

II. Digital Technology as an Enabler for a Multidisciplinary Approach to Health As the concepts of connected living and the digital lifestyle evolve, stakeholders in the technology sector are developing strategies to advance them. Health has been recognized as a critical element in this space with significant potential for new investments. Among private-sector players, both the technology sector and the health sector are well positioned to bring their core competencies to bear in the development of digital health initiatives and broad strategies. Governments also have a clear interest in improving population health and well-being. Therefore, there is

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a unique opportunity for public–private sector collaboration in digital technology to enable a multidisciplinary approach to address the health needs of populations. Barriers to this approach include a lack of support and infrastructure that allows access and affordability to digital health technologies, as well as the interoperability of systems to increase ease in usage and minimize inefficiency. Through this approach, technology can be an enabler for patient- and community-centric models to drive the digital health agenda. This session will introduce established multidisciplinary business models for digital health employed by technology companies and health care companies. Participants will elaborate on the challenges and opportunities of their approaches and offer concrete ideas for solutions.

Facilitator: Ann Aerts, Novartis Foundation

10:45–11:25 am Discussion: Multidisciplinary Business Models for Digital Health Jennifer Esposito, Intel Corporation Darrell Johnson, Medtronic

11:25 am– World Café 12:45 pm

12:45–1:45 pm LUNCH

1:45–2:00 pm Discussion: Engaging Digital “Teenage” Companies in Global Health Neal Myrick, Tableau

III. Digital Health Strategies at the Country Level The use of digital technology can improve health outcomes, particularly in low-resource settings. However, a fragmented landscape of actors and interests working to implement digital health solutions can lead to a lack of coordination, waste, and unrealized benefits. To build health solutions around market needs in a coordinated integrated way, digital health strategies must be aligned with the health priorities established by countries and communities. Starting with country- and community-led priorities can aid the private sector in developing digital health strategies that are responsive to the needs of patients and communities. Collaboration among the actors of the ecosystems for health and technology advances the opportunities for business and therefore impact. This session will feature lessons learned from successful strategies based on country-level

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priorities. The discussion will explore frequent barriers and challenges and distill critical success factors.

Facilitator: Elaine Gibbons, PATH

2:00–3:30 pm Panel Presentations and Discussion Lesley-Anne Long, PATH Digital Health Initiative Olasupo Oyedepo, ICT4HEALTH Nigeria Alvin Marcelo, Asia eHealth Information Network Neal Myrick, Tableau

3:30–3:45 pm BREAK

IV. Pull Versus Push at the Community Level Public and private sectors primarily rely on a push approach to deliver health through digital health initiatives. Contrastingly, pull programs rely on input from communities, which can increase the acceptance and adoption of innovation from both the system that is establishing technologies and the individuals using technologies. Getting buy-in from both sides from the start increases the potential for success. Equally important is the necessity of documenting the outcomes of digital health initiatives in order to understand what is driving success or scale. Questions arise on how communities can be empowered to take an active role in pull programs, what incentives are needed to create the “pull” from communities, and what role community health workers play in driving the “pull” forward. This panel will aim to illuminate the answers to these questions by using examples of pull programs in the digital health space in low- and middle-income countries.

Facilitator: Bob Bollinger, Johns Hopkins University

3:45–5:00 pm Panel Presentations and Discussion Christoph Pimmer, School of Business, Northwestern Switzerland FHNW (by video conference) Adele Waugaman, USAID Larissa Fast, Fulbright-Schuman Research Scholar in the United Kingdom and Sweden Kaakpema Yelpaala, access.mobile International

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V. Tapping into Grassroots Initiatives and Entrepreneurs This session will focus on the importance and practice of cultivating an environment where grassroots entrepreneurs and initiatives are contributing to the global digital health landscape. The discussion will explore the value of fostering and gathering new ideas within digital health from the grassroots level and promising models for implementing them.

Facilitator: Anna Thompson-Quaye, access.mobile International

5:00–5:30 pm Speaker Nnamdi Oranye, Media contributor and author

VI. Review of Key Messages and Closing Remarks 5:30–6:00 pm Ann Aerts and Elaine Gibbons, Workshop Planning Committee Co-Chairs

6:00–7:00 pm Informal Reception

Appendix C

Speaker and Moderator Biographical Sketches

Ann Aerts, M.D., M.P.H., D.T.M., has been Head of the Novartis Founda- tion since January 2013, where she has played a key role in devising new policy recommendations. She has the exciting responsibility of heading an organization committed to exploring innovative solutions to public health problems. The Novartis Foundation has the challenging goals of expanding access to quality health care and eliminating diseases such as leprosy and malaria. Before her current role, Dr. Aerts was Franchise Medical Director Critical Care for Novartis Pharma in Basel and Therapeutic Area Head Cardiovascular and Metabolism in Novartis Pharma Belgium. Prior to joining Novartis, she served as Director of the Lung and Tuberculosis Association in Belgium, as Head of the Health Services Department of the International Committee of the Red Cross (ICRC) in Geneva, and was Health Coordinator for the ICRC in several countries. Dr. Aerts holds a degree in Medicine and a master’s in Public Health from the University of Leuven, Belgium, as well as a degree in Tropical Medicine from the Institute of Tropical Medicine in Antwerp, Belgium. In July 2014, Dr. Aerts was nominated by PharmaVOICE as one of the 100 Most Inspiring People in the life science industry. Dr. Aerts has authored numerous publications and is a member of the Advisory Boards of the Global Health Group of University of California, San Francisco; the Center for Corporate Responsibility and Sustainability of the University of Zürich; the OECD Network of Foundations Working in Development (NetFWD); the One Million Community Health Workers Campaign; the World Eco- nomic Forum Health Systems Leapfrogging project in Emerging Economies

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Steering Board; and a Member of the International Telecommunications Union/United Nations Educational, Scientific and Cultural Organization- Broadband Commission for Digital Development.

Robert C. Bollinger, M.D., M.P.H., is a professor of Infectious Diseases in the Department of Medicine of the Johns Hopkins University (JHU) School of Medicine, with joint appointments in the Department of International Health of the Bloomberg School of Public Health and the JHU School of Nursing. He has more than 35 years of experience in international public health, clinical research, and education in a broad range of global health priorities including HIV/AIDS, malaria, tuberculosis, leprosy, and emerging infections. Dr. Bollinger is engaged in collaborative research projects in Colombia, India, Uganda, and the United States. Dr. Bollinger is Director of the Johns Hopkins Center for Clinical Global Health Education (CCGHE), which develops and provides clinical education to health care providers in resource-limited communities around the world. Under Dr. Bollinger’s leadership, the CCGHE has developed educational and research programs in more than 20 countries, becoming a leader in the development and use of distance learning and mobile health (mHealth) technology in resource- limited settings. Dr. Bollinger’s research interests include identification of the biological and behavioral risk factors for HIV transmission, character- ization of the clinical progression and treatment of HIV and related infections, and projects focused on optimizing strategies to improve health care capacity and care delivery in resource-limited settings. Dr. Bollinger has recently been appointed Hopkins Director of a new public–private partnership between corporate stakeholders, JHU and IMEC, a Belgium-based global leader in silicon chip technology, to design and evaluate next generation point-of-care “lab on a chip” diagnostic technologies. Dr. Bollinger has published more than 170 peer-reviewed research publications and 15 book chapters. Dr. Bollinger is also an active clinician/educator who provides and supervises HIV and infectious diseases clinical care in the outpatient and inpatient settings at Johns Hopkins Hospital. Dr. Bollinger has contributed to many public health training programs, expert commit- tees, and consultations in more than 18 countries, as well as serving on the U.S. Presidential Advisory Council for HIV/AIDS (PACHA). His commit- ment to health education and research has been recognized by the Johns Hopkins Department of Medicine David M. Levine Excellence in Men- toring Award. Dr. Bollinger is Board Certified in Internal Medicine and Infectious Diseases from the American Board of Internal Medicine, having received internal medicine training at the University of Maryland Medi- cal Systems and a Postdoctoral Fellowship in Infectious Diseases from the JHU School of Medicine. Dr. Bollinger has been on the faculty at the JHU School of Medicine and Public Health since 1992.

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Jennifer Esposito, M.S., is the General Manager of the Global Health and Life Sciences organization at Intel Corporation. In this role, Ms. Esposito leads a worldwide team of technology leaders and subject-matter experts to develop solutions that use information and communication technology to transform the health and life sciences industry. She has nearly 20 years of experience on the front lines of the medical imaging industry, U.S. health systems, and academic medicine. She worked as the Executive Director for the High Value Healthcare Collaborative—a consortium that included 20 leading U.S. health systems working to improve health care quality, outcomes, and costs of care, and to serve as a model for health care reform. Ms. Esposito was also a General Manager at GE Health- care, leading the Interventional Radiology and Cardiology Service business, where her efforts focused on driving a digital transformation of the technical and customer support organization. She championed the development of an innovative, remote, proactive maintenance analytic platform that reduced customer downtime and improved overall product reliability. Ms. Esposito was awarded a patent for creating a system to track and optimize radiation dose in interventional radiology and cardiology using machine and medical imaging data. Since 2015, Ms. Esposito has served as a Core Member for the Working Group on Health for the Broadband Commission, the aim of which is to expand broadband access in every country to accelerate progress in achieving national and international development targets. She is also a Steering Committee member on the Global Health Security Agenda (GHSA) Private Sector Round- table (PSRT), and chairs the PSRT’s subcommittee on Technology and Analytics. Ms. Esposito holds an M.S. in Epidemiology and Biostatistics from the Dartmouth Institute for Health Policy and Clinical Practice, and a B.A. from Dartmouth College. She is a member of the American Associa- tion of Physicists in Medicine.

Larissa Fast, Ph.D., is a scholar and practitioner, focused on the intersection of research, policy, and practice related to humanitarianism, conflict, and peacebuilding. She is a Senior Research Fellow at the Humanitar- ian Policy Group/ODI in London (UK) and a Research Fellow with the Institute for International Humanitarian Affairs, Fordham University. Throughout her professional career, Dr. Fast has worked at both academic and policy institutions. She was a 2016–2017 Fulbright-Schuman Research Scholar at Uppsala University (Sweden) and the University of Manchester (UK). Prior to taking up the Fulbright award, Dr. Fast served as a Science and Technology Policy Fellow with the American Association for the Advancement of Science, working at the U.S. Agency for Interna- tional Development, and was an assistant professor at the Kroc Institute, University of Notre Dame (U.S.) and at Conrad Grebel University College,

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University of Waterloo (Canada). Her research examines the causes of and responses to violence against conflict interveners, such as aid workers and peacekeepers, and how to make intervention more effective and responsive. Dr. Fast is the author of Aid in Danger: The Perils and Promise of Humanitarianism (University of Pennsylvania Press, 2014), and has published extensively in both scholarly and policy-focused venues.

Florence Gaudry-Perkins founded Digital Health Partnerships (DHP), an organization focused on scaling digital health in developing and emerging countries by creating multistakeholder partnerships among government, the private sector, nongovernmental organizations, development banks, and international organizations. DHP is also involved with multiple organizations on catalyzing efforts for governments to develop national digital health strategies. Her passion for digital health built over 6 years while working as the International Director for Government Affairs for Nokia, where she helped build a large-scale mHealth initiative to address diabetes in Senegal and developed an ambitious national project in Mexico using mobile technology to address diabetes, obesity, and overweight. She works in partnership on these projects with the pharmaceutical sector, health insurance, information and community technology private sector, governments, multilateral organizations, and civil society.

Elaine Gibbons is the Executive Director of Global Corporate Engage- ment at PATH. This newly created role is designed to extend PATH’s more than 35-year history of partnership with the corporate sector to develop and scale global health innovations, with a focus on expanding the institution’s collaborations rooted in corporate responsibility and shared value strategy. Ms. Gibbons is responsible for developing and implementing corporate engagement strategies to grow PATH’s market position as a preferred partner of corporations, deeply engaging with critical partners in this field, and significantly mobilizing resources for the institution. She has 13 years of experience leading international teams and executing major strategic initiatives in financial services, with specific expertise in organizational and financial transformation. Her most recent roles have been with Russell Investments, including 2 years in Bangalore, India, where she led the development and management of all global off- shore operations as a Managing Director. Prior to her role in India, she was Managing Director of Russell’s Private Client Services Marketing & Strategic Initiatives team where she led the B2B Go-To-Market team. A UK native and Seattle resident, Ms. Gibbons is adjunct faculty at the University of Washington, Tacoma; a Board Member of Within Reach, a Washington state family services organization; and a member of Social

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Venture Partners, a local philanthropic group. She is a passionate human rights advocate and a lifelong member of Amnesty International.

Ted Herbosa, M.D., was the Health Undersecretary of the Philippines from 2010 to 2015, during which he helped achieve Universal Health Coverage and led the modernization of public hospitals through public– private partnerships (PPP). As Chief Information Officer, he achieved COBIT 5 Certification and implemented the National eHealth Strategic Framework Plan. At the University of the Philippines, he started the Fellowship Program for Trauma Surgery and the Residency Program in Emergency Medicine. He was a professor of Emergency Medicine at Universiti Kebangsaan MaJaysia from 2007 to 2010. He was also an International Associate for Johns Hopkins University, implementing the Hospital Preparedness for Emergencies (HOPE). He was part of the team of the World Health Organization’s Task Force on Safe Surgery Saves Lives. He is currently a professor of Emergency Medicine and Trauma Surgery at the University of the Philippines-Philippine General Hospital, and adjunct faculty at the National Telehealth Center at the University of the Philippines Manila. Concurrent with this professional engagement is his latest appointment as the Executive Vice President of the University of the Philippines System.

A. Reza Jafari, M.B.A., Ed.S., ABD (Ph.D.), is the Chairman and Chief Executive Officer (CEO) of e-Development International. Based in Wash- ington, DC, e-Development International is an executive advisory group that promotes, facilitates, advises, and participates in information and communication technology (ICT) initiatives for social entrepreneurships and public–private partnerships for economic development and ICT as an infrastructure for promoting access and availability of health care, education, cybersecurity, agriculture, and alternative sources of energy in developed and emerging markets worldwide. On the industry association and nonprofit front, currently Mr. Jafari is a Special Advisor to the Secretary General of the United Nations (UN); the Chairman of the Board of Directors of ITU TELECOM (International Telecommunication Union, a UN Agency); a board member of GSMA Ltd., a wholly owned subsidiary of GSM Association; the Chairman of the Board of the India, China and America Institute (ICAI); and a member of the Governor’s Council for International Business, Maryland. He also served as the Chairman of the Finance Committee for the election of Mayor Josh Cohen in Annapolis, Maryland. Mr. Jafari served as the Chairman and Managing Director of NeuStar International (2005–2008). Prior to joining NeuStar, Mr. Jafari was the Chairman and CEO of the Omega Partners, an executive advisory group based in Atlanta, Georgia (2002–2005). From 1990 to 2002, Mr.

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Jafari held various senior executive positions at Electronic Data Systems Corporation (EDS), an HP Company, including Group President of EDS’s Global Communications, Media, and Entertainment Industry Group and Managing Director of the Communications and Media Industry Group for Europe, Middle East, and Africa. Mr. Jafari’s career also includes 7 years as the Founder, President, and CEO of Satellite Conference Network and Bankers-TV Network in New York City.

Clarion Johnson, M.D., Co-Chair of the Forum on Public–Private Part- nerships for Global Health and Safety, served as Global Medical Direc- tor of ExxonMobil Corporation until his retirement in 2013. Currently, Dr. Johnson is a consultant to ExxonMobil, the Chair of the Joint Com- mission’s International and Resource Boards, and a member of the Yale School of Public Health Leadership Council. He serves on several boards, including the Bon Secours Hospital System; the Advisory Board of the Yale School of Public Health; and the Board on Global Health of the National Academies of Sciences, Engineering, and Medicine. Dr. Johnson also has a Department of Health and Human Services Secretary appointment to the National Institute of Occupational Safety and Health Advi- sory Board and was a member of the Virginia Governor’s Task Force on Health Reform, and co-chair of the Insurance Reform Task Force. He is the past Chair of Virginia Health Care Foundation and the Board of City Lights Charter School in Washington, DC. He served as an advisor and lecturer in the Harvard Medical School’s department of continuing education “Global Clinic Course” from 2005 to 2008. In 2013 he received the President’s Award from the Oil and International Petroleum Industry Environment Conservation Association, and the Oil and Gas Producers for contributions to health, and in 2012, he was the recipient of the Society of Petroleum Engineers Award for Health, Safety, Security, Environment, and Social Responsibility. In 2011 he received a medal from the French Army’s Institute De Recherche Biomedical for Project Tetrapole, a public–private partnership in malaria research. Dr. Johnson is a graduate of Sarah Lawrence College and a member of its Board of Trustees and the Yale School of Medicine. While on active duty in the U.S. Army, he also trained as a microwave researcher at Walter Reed Army Institute of Research. He is Board Certified in internal medicine, cardiology, and occupational medicine.

Darrell Johnson, M.B.A., joined Medtronic in 2007 and currently serves as the corporate Vice President of Business Solutions for the Data Science function. Mr. Johnson has built expertise in working within the medical device industry, identifying how wireless technologies and data systems may be applied to improve patient outcomes, decrease health care uti-

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lization costs, and increase provider care delivery efficiencies. His passion centers on not simply bringing technologies to market, but on the successful implementation and utilization of these technologies within the entire health care system, including patients. Prior to joining the newly formed Data Science function in 2016, Mr. Johnson spent 9 years in the cardiac rhythm and heart failure business. Under his leadership within the Connected Care business unit, he built a remote monitoring system that now has more than one million lives being monitored across 70 countries, with strong evidence reflecting the impact to both clinical and economic outcomes. With his vision of engaging patients, his team developed the world’s first patient smart phone application for personal device management. Prior to joining Medtronic, Mr. Johnson worked at GE Healthcare in Milwaukee, Wisconsin, for approximately 8 years and held several key management and marketing positions. Mr. Johnson holds a B.A. in economics and mathematics from the University of Minnesota and an M.B.A. from the Carlson School of Management, University of Minnesota.

Lesley-Anne Long is the Director of the Digital Health Initiative at PATH, Washington, DC, which is bringing private-sector technology companies, national and international governments, and nongovernmental organizations together to scale successful digital health innovations around the world. A highly experienced and internationally networked leader in the fields of global health, technology, international development, higher education, and law, Ms. Long is a progressive and innovative thinker, experienced in driving transformative change through inclusive collaboration. She works with senior-level decision makers and thought leaders in international development to deliver high-impact programs and to advocate for sustainable change in global health systems, at both the national and community level. Ms. Long is a former family law barrister, the founder and Director of HEAT (Health Education and Training) in Africa (which was nominated for a Queen’s Anniversary Prize in 2013), a former Dean at the Open University in the United Kingdom, and was the first Chief Executive Officer of the Africa Justice Foundation.

Alvin B. Marcelo, M.D., is a general and trauma surgeon by training who is currently the Executive Director of the Asia eHealth Informa- tion Network (www.aehin.org). Prior to this, he served as the Senior Vice-President and Chief Information Officer of the Philippine Health Insurance Corporation (PhilHealth). As the Director of the University of the Philippines Manila National Telehealth Center and Chief of the Medi- cal Informatics Unit, Dr. Marcelo co-established the Master of Science in Health Informatics program and conducted local and international

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research in the field of eHealth and health information systems development. He took his postdoctoral fellowship in medical informatics at the National Library of Medicine in Bethesda, Maryland, with research interests in telepathology, mobile computing, and bibliometric analysis of MEDLINE content. Dr. Marcelo is certified in the governance of enterprise information technology (CGEIT, www.isaca.org), the Open Group Architecture Framework (TOGAF, www.opengroup.org), Archimate, and COBIT5 Implementation.

Neal Myrick is the Director of social impact at Tableau, where he leads the company’s efforts in employee service and giving, community impact, and grant making. Within his role, he leads the Tableau Foundation with a mission to encourage the use of facts and analytical reasoning to solve world problems. Mr. Myrick is an active angel investor and has served as a volunteer, nonprofit board member, and philanthropist. He currently focuses on ethical data, diversity, and social equity issues.

Nnamdi Oranye, dubbed “The Innovation Guru” on Power FM 98.7’s weekly innovation segment with Victor Kgomoeswana, is passionate about the power of technology and innovation to change the lives of Africans. He is the author of Disrupting Africa, Africa’s first book that chronicles the lives of innovators and entrepreneurs changing the African landscape. His many travels and business experience across the continent have greatly contributed to his huge optimism for Africa and its bright future. He features frequently as a presenter and chairperson across various conferences in Africa, contributes regularly to media houses on the subject of innovation, and has been named among the 100 most influential names in Africa’s telecoms, media, and information and communication technology industry by the AfricaCom100 Research Board.

David Novillo Ortiz, MLIS, Ph.D., serves as a Regional Advisor working on Innovation and Digital Health at the Pan American Health Organi- zation’s (PAHO’s) regional office for the Americas of the World Health Organization (WHO) in Washington, DC. At PAHO/WHO, he advises and builds capacity in 52 countries and territories in the Americas region on matters related to eHealth (health information technology). Prior to joining WHO, he served as the Executive Advisor to the Minister of Health of Spain and he worked as an associate professor in the Depart- ment of Library and Information Science at UC3M. He obtained his Ph.D. from the Carlos III University of Madrid (UC3M), with a doctoral dis- sertation for which he was awarded with the Outstanding Thesis Award by the School of Library and Information Science. He also completed a master’s on Health Promotion and Social Development at the University

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of Bordeaux and the Public University of Navarre and he received a Cer- tificate Program in Leadership Strategies for Information Technology in Health Care by the Harvard University T.H. Chan School of Public Health.

Olasupo Oyedepo is the Project Director of the Health Strategy and Deliv- ery Foundation’s ICT4HEALTH Project in Nigeria. The project was set up to provide technical assistance to the government—through the Federal Ministries of Health and of Communications and other stakeholders— to operationalize the first year of Nigeria’s National eHealth Strategy Action Plan. Before then he was the Country Director for the ICT4SOML Project, where he led the United Nations Foundation’s support to the Nigerian Federal Ministries of Health and of Communication Technology in the development of the country’s National eHealth Strategy. He is particularly passionate about country leadership and governance of digital health investments and activities in low- and middle-income countries. He is currently playing a leading role to establish and launch the African Alliance of Digital Health Networks.

Christoph Pimmer, Ph.D., is a senior researcher, advisor, and lecturer at the University of Applied Sciences and Arts Northwestern Switzerland FHNW in Basel, Switzerland. He completed his Ph.D. at the University of Zürich and acted as a visiting researcher at the Institute of Education, University College London, and at Columbia University in the City of New York. Dr. Pimmer has been working in the fields of digital global learning and knowledge management for more than 15 years and he has developed a particular interest in global and public health. He is frequently invited to speak at international summits and conferences and with his work, he has been able to contribute to United Nations–based policy development and multi-stakeholder initiatives.

Anna Thompson-Quaye works with access.mobile International, a digital health company committed to improving access to health care through mobile and cloud-based technology. It aims to strengthen the patient– provider relationship in sub-Saharan Africa through practical, affordable, and usable technology solutions. Ms. Thompson-Quaye has a wealth of experience in program implementation, private-sector partnerships, and social investments. Her experiences and achievements range from leveraging more than $80 million in private-sector funds to support health programs to managing high-value, multifaceted private-sector partnerships, as well as complex multiyear public health programs ranging between $200,000 and $8.5 million in targeted sub-Saharan African countries. She has worked with senior executives of mid-sized and Fortune 500 companies; advised and supported their workplace/social investment pro-

78 USING TECHNOLOGY TO ADVANCE GLOBAL HEALTH

grams; and orchestrated the effective engagement of the private sector to support global health policy in her role as a focal point for the private sector at the Global Fund Board. She brings a unique blend of knowledge and professional experience in international organizations, nonprofits, and engagement with the corporate sector across multiple industries.

Adele Waugaman, M.A., is the Senior Advisor, Digital Health, at the U.S. Agency for International Development (USAID), seated in the Global Health Bureau’s Center for Accelerating Innovation and Impact. She is also an affiliated expert and former fellow at the Harvard Humanitar- ian Initiative. A frequent commentator on technology and development trends, she has been cited in news outlets including the BBC, Financial Times, The New York Times, National Public Radio, and The Wall Street Journal. Previously she was the founder and managing director of Catalyst Advisory, LLC, providing strategic, technical, and advisory support to organizations using communications technologies to strengthen global health, humanitarian assistance, and global development efforts. Prior to that she was the Senior Director of Technology Partnerships at the United Nations Foundation, where she managed a $30 million partnership with Vodafone that leveraged digital technologies to strengthen global health and humanitarian assistance. Her earlier work included providing strategic and communications support to technology companies, as well as humanitarian and human rights groups. She also has worked as a journal- ist and editor covering U.S. foreign policy and international affairs.

Kaakpema (KP) Yelpaala, M.P.H., is the Founder and Chief Executive Officer of access.mobile. He is strategic and enterprising with more than 15 years of experience working with domestic and international governments, hospitals, and health networks and spearheads access.mobile’s product and market growth. Prior to founding access.mobile in 2011, Mr. Yelpaala worked at Dalberg Global Development Advisors, advising governments, multilateral organizations, nongovernmental organizations, and businesses on a range of issues including strategy, operations, and program implementation. He also served as one of the first employees of the Clinton Health Access Initiative, working on national AIDS programs and rural initiatives across countries in East Africa and the Caribbean. Mr. Yelpaala has taught at the University of Denver’s Josef Korbel School of International Studies. He was appointed to and supports the Governor of Colorado’s Small Business Council, and he serves on the Yale School of Public Health Leadership Council. Mr. Yelpaala holds an M.P.H. from the Yale School of Public Health and a B.A. with honors from Brown University.