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1、DIGITAL-IN-HEALTHUnlocking the Value for EveryonePublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure AuthorizedPublic Disclosure Authorized International Bank for Reconstruction and Development/The World Bank 1818 H Street NW,Washington DC 20433 Telephone:202-473-1000;Internet:
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7、ollows:Digital-in-Health:Unlocking the Value for Everyone.World Bank.(2023).Washington DC.License:Creative Commons Attribution CC BY 4.0Translations If you create a translation of this work,please add the following disclaimer along with the attribution:This translation was not created by the World B
8、ank and should not be considered an official World Bank translation.The World Bank shall not be liable for any content or error in its translation.All queries on rights and licenses should be addressed to the Office of the Publisher,The World Bank,1818 H Street NW,Washington,DC 20433,USA;email:pubri
9、ghtsworldbank.org.Cover and graphic design:Theo Hawkins,World BankDIGITAL-IN-HEALTHUnlocking the Value for EveryoneTable of ContentsForeword .iAcknowledgements .iiiAbbreviations.vNavigating the Flagship Report.viiCHAPTER 1-THE VALUE OF DIGITAL TECHNOLOGY AND DATA FOR HEALTH AND HEALTH CARE .1Health
10、Systems Face Significant and Growing Challenges.3Digital Technology May Help Overcome Health Sector Challenges and Build Value.6The Time Is Ripe to Unlock the Value for Everyone.8CHAPTER 2-HOW IT STARTED:DIGITAL TECHNOLOGY AND DATA IN HEALTH.15e-Health,m-Health,and Digital Health.16Global Digital He
11、alth Milestones in the Last 10 Years.19The World Bank Journey in Digitalization and Development in the Last 10 Years.22CHAPTER 3-LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS.27What Is Known through Other Assessments of Digital Health Investments.29Investments Related to Digital Healt
12、h by the World Bank in the Last 10 Years.32Investments in Digital Health by Other Development Partners.37Private Sector Partner Perspectives on Investment in Digital Health.39Digital Health Investments:Perspectives of Patients and Providers.42CHAPTER 4-LOOKING FORWARD:A DIGITAL-IN-HEALTH FUTURE.47Ad
13、vances in Digital Technology for Better Health.48What is Meant by Digital-in-Health.54What Digital-in-Health Means in Different Contexts.58Digital in Public Health and in Health Emergencies.76CHAPTER 5-COUNTRY READINESS FOR AND DETERMINANTS OF DIGITAL-IN-HEALTH SUCCESS.79Country Readiness Measured t
14、hrough Maturity Metrics.81The Maturity of Digital Health Building Blocks around the World.82Digital Health Maturity in Relation to Digital Transformation Maturity.84Determinants of Digital-in-Health Success.86CHAPTER 6-UNLOCKING THE VALUE:TEN RECOMMENDATIONS FOR ACTION.105Getting Digital-in-Health R
15、ight:Prioritize,Connect,and Scale.107Prioritize to Solve Intractable and Growing Health Challenges .108Connect to Deliver New,More,Better,and Seamless Services .114Scale to Ensure Equitable,Replicable and Sustainable Access to Health Care for Everyone and Leave No One Behind.130Financing the impleme
16、ntation of the digital-in-health recommendations.139CHAPTER 7-CONCLUSION.145REFERENCES.149Annexes A.Ways in Which Digital Adds Value to Health Systems.169 B.Steps Involved in Conducting the World Bank Digital Health Portfolio Review.171 C.Role and Perspectives of the Private Sector in Digital Health
17、.177 D.Indicators that Constitute the Global Digital Health Monitor.195 E.Five Layers of Digital Health Leadership and Management.199 F.Indias Vision for Digital Health:a Case Study on the Future of Digital Technology and Data Embedded in Healthcare in India.203 G.Indonesias Vision for Digital Healt
18、h.225Boxes 1 The revolutionary opportunity(and risk)associated with Generative AI.50 2 The Four Subindexes of the GTMI(World Bank 2023d.).81 3 State of Evidence for Digital Health.87 4 Digital Public Infrastructure.101 5 Giga for Education:A Global Initiative to Focus on Connectivity in Education.12
19、0 6 Range of Open Standards for Exchanging Health Information.125 7 An Inclusive Approach to Public Digital Health Goods.127 8 WHO Guidelines for Assessing,Monitoring,and Evaluating Digital Health Investments.138Tables 1 Five Most Important Interventions to Save on Health Costs,Kenya,Nigeria,and Sou
20、th Africa,by 2030.7 2 Digital Health Projects Captured in the Digital Health Atlas.30 3 Digital Health Investment Estimates,by Priority Area.31 4 Digital HealthRelated Investments,by Global Practice and Region,201222.32 5 Number of Projects and Volume of Digital HealthRelated Investments,by Subcateg
21、ory,201222.35 6 World Bank Funding for Digital Health,by Subcategory of HIS-Related Investments,201222.36 7 Patient Perceptions of Digital Technology and Data in the Health Services They Use.42 8 Technology in Health Care:Advantages and Disadvantages from the Perspective of Health Care Providers.44
22、9 How Is Digital-in-Health Different from Digital Health(continued).58 10 Maturity of Aspects of Digital Health,76 Countries,2023.82 11 Challenges for and Determinants of Digital-in-Health Growth in a Country.88 12 Addressing Challenges to Create Solutions to Grow Digital-in-Health Mindsets.107 13 D
23、ifferent Recommendations Are Prioritized Depending on a Countrys Fiscal Space and Digital Maturity.142Figures 1 Proportion of Diseases Aggravated by Climatic Hazards.4 2 How Digital Technology Can Support Universal Health Coverage.6 3 Three Ways Digital Technology and Data Add Value to Health System
24、 Delivery.8 4 Range of Uses for Digital Technologies in Response to COVID-19.9 5 Types of Data on Health.10 6 Compound Annual Growth Rate of the Global Datasphere:Health Data Grow the Most Quickly.11 7 Growth in the Volume of Academic and Scientific Articles,19752018.11 8 Links between Digital Adopt
25、ion prior to COVID-19 and COVID-19 Cases and Deaths.12 9 Factors Contributing the Most to COVID-19 Deaths and Cases after the Peak.13 10 Countries with Strategies for Universal Health Coverage,e-Health,Health Information Systems,and Telehealth.17 11 The Rapid Rise in Mobile Subscriptions per 100 Pop
26、ulation,by Region,19602021.18 12 Key Moments in Digital HealthRelated Development Relevant to Low-and Middle-Income Countries .20 13 World Bank:Five Policy Priorities to Support Digitalization and Development.25 14 Investment by the World Bank in Disruptive Technology in Health,Education,and Social
27、Protection,South Asia,in 2020.30 15 Digital HealthRelated Investments,by Type and Region,201222.33 16 Changes in Type of World Bank Digital Health Investment Prior to COVID Programs,201120.34 17 The Opportunity to Engage with the Private Sector on Digital Health.39 18 Burgeoning Applications of Digi
28、tal Technology in Health and Health Care.49 19 Use of Generative AI in Radiology.51 20 The Health Digisphere:Data on Health,Health-Related Information Systems,and Technologies Working together to Improve Health.54 21 From Digitalization to Digital-in-Health.55 22 Integrated Information System for He
29、alth Financing.60 23 Conceptual Design of Malis OPSANTE Supply Chain End-to-end Digital System.64 24 Areas in Which Artificial Intelligence Is Being Used in the Drug Development Cycle.67 25 Global Digital Health Monitor Index Results,by Country Income Level,May 2023.83 26 Global Digital Health Monit
30、or Index Results,by Region,May 2023.84 27 Correlation between GovTech Maturity Index 2022 and Global Digital Health Monitor Index 2023.85 28 Personal Data Protection Legislation Differs Markedly by Country Income Status.94 29 Internet Affordability as a Share of Monthly Income.95 30 Digital Disconti
31、nuity Resulting in Data Collection Efforts and Compromises in Data Quality.97 31 Disconnected,Unlinked Information Systems.98 32 Three Areas Needed for Digital-in-Health to Add Value.108 33 Sequencing of e-Health Development,Montenegro.109 34 Tiers of Evidence from the UK Evidence Standards Framewor
32、k for Digital Health Technologies.111 35 A Road Map for Digital Health Investments,Tanzania,201723.116 36 Connected,Linked,and Distributed Information Systems with Core Central Registries 121 37 Use of Collected Data at the Operational Level.123 38 Eliminating Digital Discontinuity Through Electroni
33、c Health Record Approaches.123 39 Digital-in-Health Growth Is Incrementally Accelerated through Positive Feedback Loops.137 40 Comparing Fiscal Space for Health with Digital Health Maturity and GovTech Maturity.141 41 Digital Health Portfolio Identification Process.174 42 How Digital Health Supports
34、 Health Systems.183 43 Areas in which Digital Health Adds Value in Health Care.183 44 How Digital Health Reduces Fragmentation in Health Care Delivery.184 45 Digital Health Adds Value by Driving Financial Savings or New Streams of Revenue.185 46 Digital-in-Health Governance Implementation and Manage
35、ment:Five Layers.199 47 Indonesias Challenges and Vision for Growing Its Digital-in-Health Vision.225Foreword Over the past decades,the health of the worlds population has improved.Fewer children are dying at birth or at a young age;individuals living with HIV can now enjoy good health for many year
36、s;and both men and women are living more comfortably and longer.Yet,for billions of people,the promise of a healthy,long,and productive life still feels unattainable.Governments that have made progress in enhancing the health of their populations have applied digital technology to strengthen health
37、systems,boost health financing,make public health more effective,and reach more underserved and vulnerable populations.It is becoming clear that the future of health care is embedded in technology and linked to innovations in data.No longer is digital health the purview solely of those who are curio
38、us about technology.Digital technology is at the core of efforts to strengthen health systems:digital-in-health.As digital-in-health is integrated across essential health system functions,governments and stake-holders must maintain and reinforce the foundational building blocks that are necessary fo
39、r digital technology to operate successfully.They must prioritize to solve significant health challenges,help different areas of the health system become connected to deliver new and better health services that the changing world requires,and scale up to ensure equitable access to health care for ev
40、eryone.This will involve surpassing important challenges,but key lessons are already being learned:grow leadership,put data governance front and center,engage the private sector,create and build on the evidence on what works,and focus on long-term sustainability.In 2022,the World Bank committed to s
41、upporting five pillars of the global agenda for digitalization and development:(a)digital infrastructure,(b)digital platforms,(c)digital enablers,(d)digital safeguards,and(e)the crosscutting areas of gender and social inclusion and regional and inter-national collaboration.Investments in data and te
42、chnology will be needed across health systems,education,and social protection to increase human capital.These investments should be aimed at building trust and capacity,realizing equity,and narrowing rather than widening the digital divide.Now the real work begins:the extensive endeavor to achieve s
43、ignificant progress in digital technology and connected data systems that people will trust and all may access.Countries will drive the change.The goal of this flagship report is to provide governments and other stakeholders with practical guidance on where to start,regardless of a countrys digital
44、maturity or fiscal challenges.The World Bank remains ready to assist countries everywhere in reaching their full potential in the use of digital technologies to protect and accelerate the growth of human capital.Mamta Murthi Vice President:Human Development World BankiiiAcknowledgements This report
45、is a deliverable of the Digital Health Flagship Program of the World Banks Health,Nutrition,and Population Global Practice(HNP GP).The World Bank team responsible for producing the flagship report consisted of the following World Bank and International Finance Corporation(IFC)team members:Marelize G
46、rgens(digital health team lead),Gianluca Cafagna,Charles Dalton,Tiago De Oliviera,Jammie Feliciano,Cece Feng,Kajali Goswami,Anna Koziel,Matthew Hulse,Ashini Patel,Christoph Rockmore,Zlatan Sabic,Malarvizhi Veerappan,and Yi Zhang.The team acknowledges the valuable contributions of the following colle
47、agues and partners in producing the report:Countries that shared their experiences and knowledge through case studies and other efforts:Ministries of health of the following countries:Argentina,Burundi,Cambodia,India,Indonesia,Lesotho,Maldives,Panama,Peru,Serbia,Tajikistan,and Vietnam.World Bank sta
48、ff and consultants who have supported aspects of the digital health flagship report analysis and provided inputs:World Bank Group staff:Kyoko Okamura,Nejma Cheikh,Jed Friedman,Meera Shekar,Tamer Rabie,Stephen Dorey,Christoph Kurowski,Michelle Ashwin Mehta,Ana Maria Munoz,Monique Mzarek,Zara Shubber,
49、Nagaraja Harshadeep(Harsh),Haishan Fu,Vyjayanti Desai,Jonathan Marskell,Cem Dener,Gabriel Catan,Christoph Kurowski,Suresh K Mohammed,Yovav Gavish,Tina George,Alex Twinomugisha,Victoria Strokova,Subhashini Subramanian,Iffath Sharif,Rahul Pandey,Mohini Kak and Hermann Donfouet.World Bank Group consult
50、ants:Yai Ellen Gaye,Wuleta Lemma,Robert Zimmermann,Megan McCormick,Harriet Blest,and Kathy Ward.World Bank Digital Health Technical Working Group members:Ali Habib,Fatimah Abubakar Mustapha,Hermann Donfouet,Iffat Mahmud,Lombe Kasonde,Martin Mpungu Lutalo,Miriam Mamoon Zaki,Mohirjon Ahmedov,Nejma Che
51、ikh,Opope Matala,Parviz Ahmadov,Reem Hafez,Ruchira Shukla,Sang Minh Le,and Somil Nagpal.World Bank HNP GP digital health portfolio review team:Qi Xue,Kevin William Conklin,Yai Ellen Gaye,Isha Arora,Miheer Prakash,Alya Binti Shaiful Bahari,and Gunjan Maheshwari.World Bank HNP GP leadership and commun
52、ications team:Juan Pablo Uribe(Global Director),David Wilson,Francisca Ayo Akala,Tania Dmytraczenko,Michele Gragnolati,Trina Haque,Magnus Lindelow,Rekha Menon,Ernest Messiah,Aparnaa Somanathan,Gaston Sorgho,Monique Vledder,Feng Zhao,Mukesh Chawla,Toomas Palu,Alexandra Humme,Charlotte Ampaire and Cle
53、mentine Murer.World Bank peer reviewers of the Flagship report:Mariam Zaki(IFC),David Satola(LEG),Rami Aman(DD GP),David Wilson(Program Director,HNP GP),Somil Nagpal(East Asia and Pacific HNP GP),Keith Garrett(Practice Manager,DECAT),Stela Mocan(Practice Manager,ITS),and Alex Twinomugisha(EDU GP).iv
54、World Bank contributors to the implementation know-how briefs and case studies:Ali Habib,Aldilas Achmad Nursetyo,Aakash Mohpal,Dinesh Nair,Federica Secci,Gabriel Aguirre Martens,Lander Bosch,Maria Eugenia Bonilla-Chacin,Mirja Channa,Muhammad Hardhantyo Puspo Wardoyo,Noel Chisaka,Nareth Ly,Olivier Ba
55、senya,Pandu Harimurti,Parviz Ahmadov,Paul Jacob Robyn,Paula Giovagnoli,Rahul Pandey,Somil Nagpal,Suresh K Mohammed,Vanina Camporeale,Laura Di Giorgio,Laurence Lannes,Ha Thi Hong Nguyen,Reem Hafez,Lombe Kasonde,Nejma Cheikh,Chrys Thomas,Aida Gadiaga,Cem Dener,Jeremy Veillard,Hermann Donfouet,Anat Lew
56、in,Saa Rikanovi,Nada Teodosijevi,Sang Minh Le,Boris Volkov,Gabriel Catan,Monique Mrazek,Harriet Stella Blest,and Giacomo Assenza.External contributors and idea sharers:David Novillo(WHO EURO),Alain Labrique(WHO Geneva),Garrett Mehl(WHO Geneva),Ilona Kickbusch(Geneva Graduate Institute),Anurag Agarwa
57、l(Ashoka University),Adele Waugaman(USAID),Amarynth Sichel(USAID),Merrick Shafer(USAID),Daniel Rosen(US CDC),Karin Kallander(UNICEF),Sean Blaschke(UNICEF),Marcelo Jose DAgostino(PAHO),Carine Gachen(GAVI),Rigveda Kadam(FIND Diagnostics),Marta Fernandez Suarez(FIND Diagnostics),Rebecca Distler(McGover
58、n Foundation),Meredith Kimball(Gates Ventures),Lisa Ramon(Bill and Melinda Gates Foundation),Tracey McNeill(Bill and Melinda Gates Foundation),David Wilson(Bill and Melinda Gates Foundation),Ethan Wong(Bill and Melinda Gates Foundation),Jean Kagubare(Bill and Melinda Gates Foundation),Melissa Miles(
59、Bill and Melinda Gates Foundation),Gaurav Bhattacharya(Bill and Melinda Gates Foundation),Patty Mechael(HealthEnabled),Smisha Agarwal(Johns Hopkins University),Dirk Muller(FCDO),Hannah Chirgwin(FCDO),Niki OBrien(Imperial College London),Kirsten Mathieson(Transform Health),Barakissa Tien-Wahser(GIZ),
60、Mark Landry(The Global Fund)and members of digital health donors group.World Bank support staff:Jammie Feliciano,Susan Sebastian,Corinne Gonzalez,Marize de Fatima Santos,Juliette Makandi Guantai,and Vinod Beri.World Bank design staff:Theo Hawkins and Richard Ponsonby.The team apologizes to any indiv
61、iduals or organizations inadvertently omitted from this list.vAIArtificial IntelligenceDD GPDigital Development Global PracticeDPIDigital Public InfrastructureEDU GPEducation Global Practice GDHMGlobal Digital Health MonitorGOV GPGovernance Global PracticeGPTGenerative Pretrained TransformerGTMIGove
62、rnment Technology Maturity IndexHISHealth Information SystemHNP GPHealth,Nutrition and Population Global PracticeICTInformation and Communication TechnologyIFCInternational Finance CorporationITInformation TechnologyPADProject Appraisal DocumentPPPPublic-Private PartnershipSPJ GPSocial Protections a
63、nd Jobs Global PracticeUHCUniversal Health CoverageWHOWorld Health OrganizationAbbreviationsviviiNavigating the Flagship ReportThis report describes how governments can use digital technologies and data to deliver new,more,better,and seamless health services that people can easily want,access,and re
64、ly on.It lays out recommendations to be implemented by governments and stakeholders to unlock the value of digital technology for all and describes how the World Bank can support this process along the way.The report is structured as follows:Chapter 1 describes the value of digital technology and da
65、ta to low-and middle-income countries;it concludes that the time is ripe to unlock this value for everyone.Reflecting on the origins of technology use in health care,Chapter 2 provides a brief history of digital technology and data in health systems,as well as the World Banks evolving focus on digit
66、alization during the last 15 years.Looking back,Chapter 3 quantifies and describes the World Bank financing for digital health in the last 10 years,as well as the types of digital health investments made by other development partners and the private sector.It also summarizes the perspectives of pati
67、ents,providers,and communities on the value of these investments and how to improve the value in the future.Looking forward,Chapter 4 defines the next wave of evolution to unlock the value for everyone:no longer a narrow focus only on digitalization,but an inclusive,embedded,and infused focus on dig
68、ital-in-health.Chapter 5 examines the readiness of low-and middle-income countries to embrace and realize a digital-in-health future.The maturity of digital health systems is examined in the context of the maturity of digital transformation across all of government.Based on case studies of country e
69、xperiences,the chapter concludes with a description of 11 deter-minants that are instrumental in the ability of countries to extract the most value from digital technology and data for better health.Chapter 6 offers 10 recommendations to help countries make progress in prioritizing,connecting,and sc
70、aling up digital technology and data for better health and describes how the World Bank can support countries along this journey.Chapter 7 concludes by providing metrics of progress that governments and stake-holders might want to consider as they pivot investments in digital technology and data to
71、unlock the value for all.1Chapter 1the Value of Digital Technology and Data for Health and Health Care If health care reform 1.0 was about improving coverage,I would say health care reform 2.0 is going to be about improving delivery.In all sorts of technology-enabled ways,thats the opportunity here.
72、”Sachin Jain,Chief Medical Officer,CareMore-Health System“DIGITAL IN HEALTH:UNLOCKING THE VALUE FOR EVERYONE2Key Messages in this Chapter yImproving health is becoming more difficult,not easier.Despite immense progress,long-standing health system challenges in low-and middle-income countries linger.
73、Disparities in health and health care persist and have grown because of the pandemic.The challenges have been compounded by both sudden-onset and more slowly growing crises that increase the volume and types of health care required,a situation that is likely to continue for the foreseeable future.A
74、pivot to preventive care and public health is also under way.yHealth systems are under pressure to deliver new,more,higher-quality,and seamless services during a difficult period of limited fiscal space.yIt is not only the kinds of health services that need to expand,improve,and change;populations t
75、hat want to protect and improve their health and who need care have also changed.yResponding to these challenges,health systems areas complex adaptive systemsin constant flux.Policy makers and planners both engineer and react to these ongoing iterative cycles of change.The experience of successful c
76、ountries shows that digital technology and datadesigned and implemented iteratively with patients and stakeholders at the centerare key aspects of well-functioning health systems that are able to respond to the added pressures emerging in the twenty-first century.yDigital technology and data can add
77、 immense value to health systems.Digital technology can strengthen health systems,improve health financing,make public health care more effective,and reach underserved populations.Digital technology can make health services more personal,prevent increases in health care costs,reduce differences in c
78、are,and make the job easier for those who provide health services.It can also enhance efficiency.For instance,connected electronic health records and virtual interactions such as telemedicine can generate up to 15 percent more efficiency gains and free resources to address the other needs of patient
79、s.yFor three reasons,the time is ripe for this value to be unlocked:More health data than ever are being collected and are ready to be used.Innovation is driven by the need to deliver new,more,better,and seamless health services and prepare for future crises with less funds,while addressing long-sta
80、nding inequities.Experiences during the COVID-19 pandemic have shown that digitalization can make a real differenceCHAPTER 1:THE VALUE OF DIGITAL TECHNOLOGY AND DATA FOR HEALTH AND HEALTH CARE3Health Systems Face Significant and Growing ChallengesPeople all strive for health and well-being,and healt
81、h systems support this goal.Humans strive to live long and happy lives devoid of illness and rich with opportunity,connection to others,and contributions to society.For this to materialize,a multifaceted approach is needed,one that includes preventing disease and injury,promoting health and well-bei
82、ng,and providing timely,high-quality,affordable,and well-coordinated health care services that people need and in which they play an active role.Health systems support efforts to prevent,promote,and provide for better health and well-being through good stewardship,the creation of resources,supplying
83、 finance,and the delivery of services(Darrudi et al.2022).Despite immense progress,long-standing health system challenges persist in low-and lower-middle-income countries.While the progress is evident,health systems in these countries are still in the grips of myriads of difficulties that impede the
84、ir ability to deliver high-quality health services that everyone can easily access,afford,want to use,like,and value.Among the most intractable challenges facing health systems are inequity in health care delivery,resulting in disparities in health outcomes;too few skilled and too many underskilled
85、health workers;inequality in the access to and affordability of health services;the inconsistent quality of health services;uncoordinated health care delivery;limited coordination between private and public sector providers;inconsistent clinical pathways for the same diagnoses;administrative complex
86、ity;overtreatment;piecemeal health information systems with disjointed and unprotected data;insufficient financing;inefficient flows of funds;and a risk-averse culture wary of change.In addition,evidence is not being used adequately to guide health care,resulting in suboptimal,sometimes ineffective
87、care.Indeed,according to one estimate,only 50 percent to 60 percent of care is delivered in accordance with the highest level of evidence or consensus-based guidelines,and the rate of adverse events(1 in 10)has not declined in over 20 years(Braithwaite 2018).There is also sizable inefficiency.Thus,S
88、hrank,Rogstad,and Parekh(2019)reckon that nearly 30 percent of health care spending is wasted.These enduring health system challenges have been compounded by both sudden-onset and more slowly growing crises,a situation that is likely to continue for the foreseeable future.In the past few years,these
89、 challenges have been amplified by sudden-onset,large-scale health emergencies,such as the COVID-19 pandemic,other disease outbreaks,such as periodic Ebola and cholera outbreaks,escalating conflict,and natural disasters,such as the 2023 earthquake in Trkiye.Furthermore,health DIGITAL-IN-HEALTH:UNLOC
90、KING THE VALUE FOR EVERYONE4systems must respond to more slowly growing health crises that add pressure,such as(a)the impact of climate on health(see Figure 1:over 60 percent of all known human pathogens will be aggravated by climatic hazards)(Mora et al.2022,WHO 2023b);(b)the rising shares of older
91、 people with more complex,chronic medical needs;(c)significant increases in the need for mental health services;and(d)the growing burden of noncommunicable diseases,the cause of 75 percent of all deaths in the world in 2022(WHO 2023c).Post-pandemic recovery continues to take a toll.Health systems mu
92、st also account for their role in greenhouse gas emissions,considering that health care delivery contributes between 3 percent and 10 percent of global carbon dioxide emissions(Mercer 2019).Figure1 Proportion of Diseases Aggravated by Climatic Hazards Source:Based on Mora et al,2022.Besides these ch
93、allenges,a pivot toward public health and the integration of public health in health systems is occurring.In the first half of the twentieth century,gains in life expectancy were mostly driven by significant improvements in public health,while the contribution of medical care toward these gains was
94、comparatively modest.By the 1960s,medical care emerged as the primary factor extending life expectancy.Yet,the life expectancy increases relating to medical care were more modest than the large increases in public healthdriven life expectancy gains(Bunker 2001).This is because only 10 percent of pre
95、ventable deaths are associated with medical care;the rest are related to lifestyle factors,environmental factors,and genetics,all of which require public health solutions(Shortell 2013).The demographic,nutritional,and epidemiological transitions are driving a rise in the share of the worlds populati
96、on that exhibits unhealthy lifestyles,which means this will be a bigger challenge in the future.It also means it is likely that public healthdriven life expectancy increases will emerge in the future.For these anticipated gains to be realized,a 2023 Lancet Commission has suggested that closer synerg
97、ies among universal health coverage,health security,and health promotion are needed(Agyepong et al.2023).24815761%39%Infectious diseases that are aggravated by climate hazardsInfectious diseases that are not aggravated by climate hazardsCHAPTER 1:THE VALUE OF DIGITAL TECHNOLOGY AND DATA FOR HEALTH A
98、ND HEALTH CARE5Disparities in health and health care persist and have grown because of the pandemic.The COVID-19 pandemic has highlighted the persistent challenge of inequity in health and health care.For example,more than half the worlds population does not have timely access to surgical care.Thus,
99、although they represent 48 percent of the worlds population,low-and lower-middle-income countries account for only 6 percent of the surgical procedures performed annually(Meara et al.2015).Only 29 percent of obstetricians are based in these countries,though these countries show the highest rates of
100、childbirth.To improve equity,the global health community needs to focus on more than inequities in service delivery and in the distribution of health workers(PLOS Medicine Editors et al.2016).It has been suggested that global health equity should be defined in terms of equitable health outcomes(prod
101、ucts),but also in terms of how the services are delivered(processes)and the persons involved in designing and implementing the services(partnerships)(August et al.2022).It is clear from the above that health systems are under pressure to deliver new,more,higher-quality,and seamless services during a
102、 difficult period of limited fiscal space.Because of the pressure,more health service delivery opportunities need to be delivered though the limited number of health facilities and by the limited number of health workers in the current environment of often stagnant or shrinking health budgets.This i
103、s particularly the situation in low-income countries and in the countries in fragile,conflict,and violent settings that need the most help.Health care needs to be improved,expanded,and reformed,but the populations that access and need health care are also not the same now as they once were.Todays po
104、pulations have different preferences,needs,knowledge,and perceptions about their own health and health care relative to populations in the past.Todays populations are more highly digitally connected than ever and have a growing sense of the health care they want,how they want to access and receive h
105、ealth care,and the health information they are willing to share(Lupton 2021).What will be required for health systems to adapt to these growing and shifting challenges?Health systems are complex and are in a constant state of flux,characterized by incremental cycles of learning,adaptation,and change
106、(Paina and Peters 2012).Making health system changes endure is difficult.Health systems often suffer from a take-up problem,a diffusion problem,and a sustainability problem(Braithwaite 2018).A 2017 global review across 60 health systems as diverse as the health systems of Rwanda and Vietnam found th
107、at four factors were common in successful efforts to achieve effective,lasting change:(a)the acorn-to-oak tree principle(that is,a small initiative that tackles a specific problem may lead to systemwide impacts and change,instead of large,systemwide,long-duration reforms);(b)the data-to-information-
108、to-intelligence principle DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE6(the role of information technology IT and data is becoming more critical for delivering efficient and appropriate care,but must be converted into useful intelligence);(c)the many hands principle(concerted action among stak
109、eholders is key);and(d)the patient-as-the-preeminent-player principle(individuals are at the center of change)(Braithwaite et al.2017).In all four of these areas,technology and data are relevant.Digital Technology May Help Overcome Health Sector Challenges and Build ValueTechnology and datadesigned
110、and implemented iteratively with and by patients and stakeholdersare clearly catalytic components of the current wave of health system changes.Digital technology and data can add immense value to health systems and to the health of the population in several ways:a.Experiences in countries have shown
111、 that digital technology strengthens health systems,improves health financing,makes public health more effective,and reaches underserved populations.b.Used effectively,digital technology makes health services more personal,prevents health care costs from increasing,reduces differences in care,and ma
112、kes the provision of health services easier.c.Digital technology supports progress toward universal health coverage(Figure 2).Digital technology and data by themselves are not sufficient to realize universal health coverage,but they are necessary.Governments and other actors may not be able to addre
113、ss health challenges fully without them.Figure2 How Digital Technology Can Support Universal Health CoverageSource:Adapted from Wilson et al.2020.CHAPTER 1:THE VALUE OF DIGITAL TECHNOLOGY AND DATA FOR HEALTH AND HEALTH CARE7d.Digital technology and data can increase efficiency and save money.A revie
114、w by McKinsey&Company(2023)finds that the three largest economies in AfricaNigeria,Kenya,and South Africa could save 15 percent of health system costs by scaling up five digital solutions(Table 1).Given the constraints on fiscal space in the health sector faced by many low-and middle-income countrie
115、s,knowing concretely that digital technology can improve efficiency is game changing.Table1 Five Most Important Interventions to Save on Health Costs,Kenya,Nigeria,and South Africa,by 2030Digital solution%of total efficiency gains inKenyaNigeriaSouth AfricaVirtual interactions,which include video vi
116、sits with doctor/clinician,remote monitoring,and e-triage to determine health care needed 43%35%39%Going paperless through health information exchanges and electronic health records30%26%30%Decision intelligence systems(like supply chain predictive systems or clinical decision support,or hospital di
117、gital twin systems)9%10%12%Workflow optimization and simplification 10%16%11%Patient-focused interventions,including patient self-care and patient self-service(like for appointment scheduling)8%13%8%TOTAL100%100%100%Source:World Bank staff calculations based on data from McKinsey&company 2023.e.Digi
118、tal technology supports health service delivery in terms of data and reporting,clinical and administrative processes,and communication and integration(Figure 3,and see details in Annex A)DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE8Figure3 Three Ways Digital Technology and Data Add Value to He
119、alth System DeliveryThe Time Is Ripe to Unlock the Value for EveryoneThere are three reasons why the time is ripe for the health sector to unlock the value of digital technology and data for better health for everyone.First,in responding to COVID-19,new digital technologies were rapidly deployed,cre
120、ating momentum.The COVID-19 pandemic brought about substantial changes in the way health care services are delivered,leading to an unprecedented surge in the use of digital tools for health service provision,the promotion of public health,and the administration of COVID-19 and other vaccines(Budd et
121、 al.2021;Golinelli et al.2020)(Figure 4).Technology was useful and important not only in emergency type services that COVID-19 required,but also for the durability of routine health services.The pandemic offered an opportunity to accelerate the implementation of digital health CHAPTER 1:THE VALUE OF
122、 DIGITAL TECHNOLOGY AND DATA FOR HEALTH AND HEALTH CARE9solutions that may have been recognized as options prior to COVID-19 and to understand the preconditions that favored the implementation of such solutions,particularly in telemedicine(Baudier et al.2023).This generated momentum in efforts to as
123、similate technology and data as central components in the ongoing evolution of health systems.Figure4 Range of Uses for Digital Technologies in Response to COVID-19Source:Budd et al.2020.Second,the amount of data on health and health care is growing at staggering rates,but these data are not yet bei
124、ng used to maximum potential.Countries have multiple sources of data about health.Some are generated in the health sector,while other data on health are located outside the health sector,such as data on social grants or the DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE10educational status of an
125、 individual(Figure 5).Globally,the amount of data has exploded and continues to grow rapidly(global datasphere).An estimated 30 percent of the global datasphere consists of health data(Reinsel et al.2018).The health datasphere is the global volume of health data flows in the world(Floridi 2007).Up t
126、o 2025,health data are anticipated to exhibit the highest compound annual growth rate of data in any sector(Figure 6).The academic literatureapproximately 30 percent of which is relevant for the health sectorhas exponentially increased in the last several decades.The annual growth rate has more than
127、 doubled,from 3 percent in the 2000s to almost 7 percent in the 2010s(Johnson,Watkinson,and Mabe 2018)(Figure 7).More than half of it is available in open-access journals(STM 2023).These data are not being used.It takes,on average,17 years for new medical evidence to be translated into routine medic
128、al practice(Morris et al.2011).That duration represents almost half the career of a practicing physician.Figure5 Types of Data on HealthChapter 1:the VaLUe OF DIGItaL teChNOLOGY aND Data FOr heaLth aND heaLth Care11Figure6 Compound Annual Growth Rate of the Global Datasphere:Health Data Grow the Mos
129、t QuicklySource:RBC Capital Markets calculations based on data of Coughlin et al.2018;Reinsel et al.2018.Figure7 Growth in the Volume of Academic and Scientific Articles,19752018Source:Johnson,Watkinson,and Mabe 2018.Note:With over 1.8 billion entries,Dimensions.AI is the worlds largest linked resea
130、rch database.ESCI WoS=emerging sources citation index in the Web of Science.Scopus=a database of the academic publisher,Elsevier,with information about the abstracts and citations of Elseviers published peer-re-viewed literature.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE12Third,countries wit
131、h higher levels of digital adoption prior to the pandemic responded more effectively to the pandemic,exhibited more decisive government action,and,as a result,had fewer COVID cases and deaths.In their analysis,Heinrichs et al.(2022)find that a countrys level of digital adoption(prior to COVID-19)was
132、 almost as influential as demographic and lifestyle factors in predicting COVID-19 deaths and cases(Figure 8).A scoping review of the causes of COVID-19 cases and deaths identified the lack of digital infrastructure as one of the strongest contenders(Figure 9).The data show that,as part of future pa
133、ndemic preparedness efforts,the expansion of digital technology should become a cornerstone of health system resilience and pandemic preparedness.Figure8 Links between Digital Adoption prior to COVID-19 and COVID-19 Cases and DeathsSource:Heinrichs et al.2022.Note:Panel a shows that the level of dig
134、ital adoption prior to COVID-19 was as instrumental in deter-mining the total COVID cases per million population as biological determinants,such as the share of females who smoke and the share of the elderly in the population.Panel b shows that countries with larger changes in post-peak new COVID-19
135、 cases had higher levels of digital adoption prior to COVID-19.CHAPTER 1:THE VALUE OF DIGITAL TECHNOLOGY AND DATA FOR HEALTH AND HEALTH CARE13Figure9 Factors Contributing the Most to COVID-19 Deaths and Cases after the PeakSource:Heinrichs et al.2022.15Chapter 2how it Started:Digital technology and
136、Data in HealthThe past is kind enough to give you lessons.The present is kind enough to give you opportunities.The future is kind enough to give you both.”Matshona Dhliwayo,entrepreneur,philosopher and author“DIGITAL IN HEALTH:UNLOCKING THE VALUE FOR EVERYONE16Key Messages in this Chapter yEarly eff
137、orts to introduce digital technology and data in the health sector focused on the digitalization of health data and on creating health information systems to manage health data.The use of digital technology in health later expanded to focus on mobile applications in health care.yThe last decade has
138、been monumental for digital health because of global initiatives,strategies,global principles,and commitments.yThe World Bank has undergone its own journey to realize the promise of disruptive technology and digitalization for development.Throughout,the World Bank has committed to supporting the eff
139、orts of countries to use digitalization to improve sectoral outcomes and systems,including through the World Bank health portfolio.e-Health,m-Health,and Digital HealthA focus on e-health in early 2000s:The origins of the term e-health can be traced to 2000.At the time,e-health was an attempt to expa
140、nd the focus from medical informatics to the use of technology in the business of delivery health care(Pagliari,2005).This is reflected in the definitions of Eysenbach(2001)and Eng(2004):“E-health is an emerging field in the intersection of medical informatics,public health and business,referring to
141、 health services and information delivered or enhanced through the Internet and related technologies.”Eysenbach(2001,1)“E-health is the use of emerging information and communication technology,especially the Internet,to improve or enable health and health care.”(Eng,2004,238)CHAPTER 2:HOW IT STARTED
142、:DIGITAL TECHNOLOGY AND DATA IN HEALTH17The first World Health Assembly resolution on e-health was passed in 2005.The resolution urged member states to draw up a long-term strategic plan for developing and implementing e-health services(resolution WHA58.28).This resolution heralded in a new era of d
143、igitalizing health data and creating health information systems(Figure 10).Figure10 Countries with Strategies for Universal Health Coverage,e-Health,Health Information Systems,and TelehealthSource:WHO 2016Because of the vast need and the low hanging fruit nature of it,e-health efforts initially focu
144、sed on digitalizing health data and creating health information systems(HISs).An HIS is a system that integrates data collection and the processing,reporting,and use of the information necessary for health systems to work better.Most countries have several HISs,such as a district information system(
145、to manage health service delivery data in a district),a human resource information system(to manage health worker and health administrator data),a logistics management information system(to manage supply chains),and a laboratory information system(to manage data for clinical and public health labora
146、tories).By the late 2000s,the focus broadened to m-health.In global health circles,the term m-healthshorthand for mobile health,or,more accurately,the application of mobile DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE18technologies in health care deliverywas first formally used at the 2008 e-H
147、ealth Connect Conference,which brought together experts and stakeholders to explore the intersection of health care and technology.At the time,it was defined as the delivery of health care services through mobile communication devices(Torgan 2009).An m-health application generates digital data that
148、need to be managed through some type of information system.These expanding shifts in focus from e-health to m-health occurred during a period when barriers to entry were significantly lowered because cell phone subscriptions per 100 population rapidly increased(Figure 11).Figure11 The Rapid Rise in
149、Mobile Subscriptions per 100 Population,by Region,19602021Source:World Bank 2023b.CHAPTER 2:HOW IT STARTED:DIGITAL TECHNOLOGY AND DATA IN HEALTH19Over time,because the range of technologies and their applications expanded,the focus broadened to digital health.According to WHO(2020a),digital health i
150、nvolves the knowledge and practices associated with the development and use of digital technologies to improve health.Digital health expands the concept of e-health to include digital consumers and a wider range of smart devices and connected equipment.It also encompasses other uses of digital techn
151、ologies in health care,such as the internet of things,artificial intelligence(AI),big data,and robotics.In other words,digital health1 encompasses a wider range of technologies than m-health(e.g.digital x-rays and their interpretation).It is also focused on solving health system problems and improvi
152、ng health outcomes.As Xiong et al.(2023,217)put it,“digital health is a discrete functionality of digital technology that is applied to achieve health objectives”.Global Digital Health Milestones in the Last 10 YearsThe last 10 years have been momentous in digital health.In many ways,201222 can be r
153、egarded as a Rubicon on the long road to unlocking the value of digital technology and the use of data in health care.This period of digital awakening in the health sector is bookended by two momentous events:the launch of the Principles for Digital Development in 2012 and the public release of gene
154、rative AI tools(such as ChatGPT4 and Stable Diffusion)in 2022(Figure 12).Notable achievements in this period of digital awakening in the health sector include the publication of the Global Strategy on Digital Health 20202025 of the World Health Organization(WHO),approved at the World Health Assembly
155、 in 2020 and developed in response to a World Health Assembly resolution on digital health in 2018.The strategy focuses on four key objectives,all relevant for digital health investments:(a)promote global collaboration and advance the transfer of knowledge on digital health;(b)advance the implementa
156、tion of national digital health strategies;(c)strengthen governance for digital health at national,regional,and global levels,such as the Asia e-Health Information Network,the Central American Health Informatics Network,and Health Informatics in Africa;and(d)advocate for people-centered health syste
157、ms that are enabled by digital health.1 In some ways,the concept digital health is a misnomer as it is not health that becomes digital,but rather using digital technology to increase the value of health care for everyone.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE20Figure12 Key Moments in Dig
158、ital HealthRelated Development Relevant to Low-and Middle-Income Countries CHAPTER 2:HOW IT STARTED:DIGITAL TECHNOLOGY AND DATA IN HEALTH21DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE22The World Bank Journey in Digitalization and Development in the Last 10 YearsOver the last several years,the
159、World Bank has extensively supported countries as they developed public sector information systems,particularly financial management information systems(Dener et al.2011),education management information systems(World Bank 2016a;Map 1),social protectionrelated information systems,and health manageme
160、nt information systems(Otto et al.2015).Map 1 World Bank Investments in Education Management Information Systems,since 1997 Source:World Bank 2016a.Building on these investments in information systems,the World Bank has been on a journey to digitalization and disruptive technology in development,in
161、particular the transition from investing in information systems to recognizing the importance of the digital economy and the ways in which digitalization supports development goals.Key milestones during this period are the following:CHAPTER 2:HOW IT STARTED:DIGITAL TECHNOLOGY AND DATA IN HEALTH23201
162、5 World Bank report on Information and Communication Technologies For Health Systems Strengthening.(Otto et al.2015).In this report,the World Bank outlined the ways in which information and communication technology can be deployed to support health system strengthening.The report also outlines seven
163、 factors involved in advancing the e-health agenda,namely,(a)adequate physical infrastructure;(b)data and interoperability standards;(c)sufficient local capacity;(d)a supportive policy and regulatory environment,including an integrated national e-health strategy;(e)appropriate business models;(f)tho
164、ughtful partnerships aligned with local and national priorities;and(g)effective monitoring and evaluation.World Development Report 2016:Digital Dividends:(World Bank 2016b).The key message of this report is that,while digital technologies have spread rapidly in much of the world,the digital dividend
165、sthat is,the broader development benefits from using these technologieshave lagged.In many instances,digital technologies have boosted growth,expanded opportunities,and improved service delivery.Yet,the aggregate benefits have been disappointing and unevenly distributed.If digital technologies are t
166、o benefit everyone everywhere,the remaining digital divide,especially in internet access,must be reduced.The adoption of more digital technologies will not be enough.To obtain the most from the digital revolution,governments and stakeholders will also need to enhance the analog complements by streng
167、thening regulations that ensure competition among businesses,adapting worker skills to the demands of the new economy,and ensuring that institutions are accountable.2018 World Bank Development Committee Report:“Disruptive Technologies and the World Bank Group Creating Opportunities Mitigating Risks”
168、:(World Bank 2018).This report makes the point that traditional pathways to overcome critical development challenges are increasingly subject to technology-based disruptions.Disruptive technologies pose new risks,including to economic and social inclusion and to environmental and systemic sustainabi
169、lity.Despite the risks,failing to take advantage of the opportunities that disruptive technologies offer could be even more costly.In the report,the World Bank committed to supporting countries in taking advantage of the opportunities and mitigating the risks associated with disruptive technologies
170、by operationalizing the build-boost-broker value proposition.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE242019 World Bank Development Committee Report:“Mainstreaming the Approach to Disruptive and Transformative Technologies at the World Bank Group”:(World Bank 2019).In this report,a follow u
171、p to the 2018 Development Committee Report on Disruptive Technologies,the World Bank committed to five corporate actions to mainstream disruptive technology in development.2021 World Bank Independent Evaluation Group(IEG)Report:“Mobilizing Technology for Development:An Assessment of World Bank Group
172、 Preparedness”:(IEG 2021).This evaluation seeks to answer the question,how well prepared is the International Finance Corporation and the World Bank to help clients harness the opportunities and mitigate the risks posed by disruptive and transformative technologies.The answer to the question in 2021
173、 was,given the accelerating pace and complexity of technological change,the World Bank is not yet sufficiently well prepared,despite some areas of strength.Based on this evaluation,the World Bank has increased its efforts to build internal capacity and sourced specialist skills to apply digital tech
174、nology in World Bank operations.2021 World Development Report:Data For Better Lives:(World Bank 2021b).Todays unprecedented growth in data and the ubiquity of data in the lives of individuals are signs that the data revolution is transforming the world.Yet,much of the value of data remains untapped.
175、Data collected for one purpose have the potential to generate economic and social value in applications far beyond those originally anticipated.But many barriers stand in the way,ranging from misaligned incentives and incompatible data systems to a fundamental lack of trust.This World Development Re
176、port explores the tremendous potential of the changing data landscape to improve the lives of poor people,while also acknowledging the potential of data to allow activities that can harm individuals,businesses,and societies.2022 World Bank Development Committee Report:“Digitalization and Development
177、”:(World Bank 2022a).The COVID-19 pandemic has rapidly accelerated the take-up of digital products and services in developing countries.Digital platforms and services have enabled innovations that have helped reduce the health,social,and economic costs of COVID-19.They offer great potential for help
178、ing build resilience and preparedness against future crises and for mitigating and adapting to climate change.However,the pandemic has also demonstrated the importance of building strong and inclusive digitalCHAPTER 2:HOW IT STARTED:DIGITAL TECHNOLOGY AND DATA IN HEALTH25foundations during normal ti
179、mes that governments and stakeholders may rely on in realizing digital solutions to mitigate the impacts of crises effectively,and,more broadly,to contribute to the twin goals of reducing poverty and promoting shared prosperity.This report defined five World Bank policy priorities to maximize the de
180、velopment dividends of digitalization,while managing risks(Figure 13).These World Bank corporate priorities are important beacons for World Bank investment priorities,writ large.They are also priority areas for investing in digital technology for better health outcomes.Figure13 World Bank:Five Polic
181、y Priorities to Support Digitalization and DevelopmentSource:World Bank 2022a.27Chapter 3Looking Back:Digital Health Investments in the Last 10 YearsWhen spiders unite,they can tie up a lion.”Ethiopian Proverb“DIGITAL IN HEALTH:UNLOCKING THE VALUE FOR EVERYONE28Key Messages in this Chapter yThe Worl
182、d Bank undertook a detailed analysis of its investments in digital health in the last 10 years.The World Bank Digital Health Portfolio Assessment showed that(a)the World Bank has significantly supported countries in their digital health efforts(just under US$4 billion,which is 6 percent of the World
183、 Banks health portfolio);(b)investment projects in other sectors have contributed 49 percent of digital healthrelated investments;(c)the investments have been largely concentrated in South Asia and Sub-Saharan Africa;and(d)82 percent of the investments have focused on health information systems(HISs
184、)and the foundational building blocks of digital health.yOther development partners have also invested in digital health.Development partners have shared four key trends in terms of their digital health investments:(a)most investments have also been in HISs,mainly for the purpose of using these syst
185、ems to obtain data for reporting;(b)ongoing system maintenance costs have been underestimated;(c)digital capacity and literacy are weak and require ongoing investment;and(d)in future,more focus is needed on the digital health ecosystem.yThe private sector is an innovator,developer,and user of digita
186、l technologies for health care.Digital technology applications offer opportunities to reset and expand the relationship between the private and public sectors in recognition that both are needed to resolve the bigger challenges.yPatients,providers,and the community have strong and divergent views on
187、 whether and which digital technology would be most useful to them.While patients and providers see advantages and some demand it,they prefer using digital technology for administrative processes(e.g.,appointment scheduling and medical record access).There is lower demand to use digital technology f
188、or diagnostic or clinical care.Building trust and familiarity in using digital technologies for diagnostics and clinical care,will require regulatory processes,capacity,and trust.yThere is remarkable coherence from diverse stakeholders on what should change to make digital investments work for every
189、one:(a)expanding foundational infrastructure to connect every facility,every health worker and every patient;(b)addressing fragmentation,interoperability,and integration;(c)designing with the participation of individuals who will use the digital solutions;(d)building digital skills and awareness;(d)
190、improving regulations to ensure trustworthiness;(e)choosing technology that solves health sector problems and reduce disparities in health and health care;(f)ensuring continued funding;and(g)designing robust data governance systems.Heeding these voices will be instrumental to future success.CHAPTER
191、3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS29This chapter describes the current landscape of investments in digital health by the World Bank,other development partners,and the private sector.It also outlines the perspectives of patients,providers,and the community about investment
192、s in digital health and what future investments should work on.What Is Known through Other Assessments of Digital Health InvestmentsUnderstanding who has invested what in digital health is not straightforward.This is because investments in digital health are not included as a separate reporting code
193、 by the Development Assistance Committee(DAC)of the Organisation for Economic Co-operation and Development.As such,development partners do not report on development assistance for digital health separately to the DAC databases.This is also the case for countries:Transform Health(2022)found that info
194、rmation on the estimated share of annual public expenditure on health committed to digital health is not routinely available in most countries.Given that standardized information about digital health investments were not available,the World Bank team examined the approaches and results of three othe
195、r assessments (a)2021 World Bank report on Converging Technology and Human Development,(b)the WHO Digital Health Atlas,and(c)a global assessment of digital health investment needs undertaken by Transform Health before designing the methodology for the World Bank Digital Health Portfolio Assessment.a
196、.The 2021 World Bank report on Converging Technology and Human Development used a portfolio review method to estimate World Bank investments in South Asia in disruptive technology for human development.The result of their effort is illustrated in Figure 14:it shows that 62 percent of disruptive tech
197、nology investments in the health sector are in the proof-of-concept or piloting stage,while fewer are in the scaling-up or maintenance stage(Bashir et al.2021).b.The World Health Organization(WHO)s Digital Health Atlas invites,on a voluntary basis,any organization(including ministries of health or d
198、igital solution providers)to capture digital health investments in an online database.Aggregating these data by region,gives a sense of the volume of digital health investments in countries and regions.The latest data,shown in Table 2,suggest that most digital health activity occurs in Africa and So
199、uth Asia.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE30Figure14 Investment by the World Bank in Disruptive Technology in Health,Education,and Social Protection,South Asia,in 2020Source:Bashir et al.2021.Table2 Digital Health Projects Captured in the Digital Health AtlasWorld Bank regionsNumber
200、 of Digital Health projects in Digital Health AtlasEast Asia and Pacific region24East and Southern Africa region315Europe and Central Asia region54Latin America and Caribbean region38Middle East and North Africa region105South Asia region 174West and Central Africa region144Source:Data of July,14,20
201、23,Digital Health Atlas(dashboard),World Health Organization,Geneva,https:/digitalhealthatlas.org/en/-/.Note:While it is a useful resource,participation in nourishing the atlas with data is voluntary and the data contained in it,are not independently verified.Therefore,duplication is possible(e.g.,a
202、 ministry of health and a vendor could submit the same intervention to the atlass database.However,there is no reason to think that u8nder or over-reporting would be more prevalent in one region than another.The data are useful for understanding geographic differences in the volume of projects.c.Tra
203、nsform Healths 2022 assessment of digital health investment needs finds the investment needs in digital health is around US$12.5 billion(US$7.1 billion US$20.5 billion)and that there are nine priority areas of investment(Table 3).CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS
204、31Table3 Digital Health Investment Estimates,by Priority AreaInvestment area 5-year costs.Costs in 2021,US$millionsLow-cost scenario Medium-cost scenario(most realistic)High-cost scen5-year breakdown(based on the medium scenario)Digital connectivity infrastructure(connecting every health worker,heal
205、th facility and household)4,8209,69317,001Telemedicine(provision of health care services at a distance)8199831,228Decision support(digitalized job aids combining patient health information and clinical protocols)515618772Health financing(digital approaches for monitoring and reporting stock levels)4
206、00480600Supply chain management(digital approaches to manage financial transactions)255306382Data exchange and interoperability(multiple systems communicating and exchanging data)139167209Client identification and registration(identifying and enrolling clients in a patient portal)118141177Enterprise
207、 architecture,including governance,guidelines and standards for interoperability7995118Data and digital governance(regulating the use of digital technologies and data)172025Total 5-year cost7,16212,50320,512These assessments show that consistent and global data on the extent of investments and types
208、 of investments in digital health are not available and that a taxonomy of investment types does not exist.It also shows that there is a significant investment need in digital Yr 1 Yr2 Yr3 Yr4 Yr5 DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE32health and that the most significant future investm
209、ents are likely in digital connectivity infrastructure(estimated to be between 67 percent and 82 percent of total investment financing needs(Transform Health 2022).Investments Related to Digital Health by the World Bank in the Last 10 YearsThe World Bank undertook the first-ever Digital Health Portf
210、olio Assessment.The review focused on investments led by the four global practices in the World Bank with the highest likelihood of digital healthrelated investments in 201222,that is,(a)Health,Nutrition and Population Global Practice(HNP GP),(b)Digital Development Global Practice(DD GP),(c)Social P
211、rotection and Jobs Global Practice(SPJ GP),and(d)Governance Global Practice(GOV GP).The objective of the Digital Health Portfolio Assessment was to quantify the following:(a)volume of digital healthrelated investments by the World Bank,(b)digital healthrelated investments by region,(c)volume of inve
212、stment to specific aspects of digital health.The review method entailed four steps,detailed in Annex B.Table4 Digital HealthRelated Investments,by Global Practice and Region,201222RegionLeading GP,US$,millionHNP GP DD GP GOV GP SPJ GP TotalEast Asia and Pacific86m20m19m10m135mEastern Europe and Cent
213、ral Asia232m40m5m11m288mLatin America and Caribbean354m75m045m474mMiddle East and North Africa203m1m12m0216mSouth Asia469m225m77m282m1,053mSub-Saharan Africa661m561m427m135m1,784mGlobal/multi-region12m00012mTotal2,017m(51%)922m(23%)540m(14%)483m(12%)3,962mThe review shows that,overall,the World Bank
214、 invested just under US$4 billion in digital health-related efforts in 201222.Of the total amount,51 percent was in health CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS33sector projects,and 49 percent was managed by other sectors(DD GP,23 percent;GOV GP,14 percent;and SPJ GP
215、,12 percent).Of the World Banks total HNP investment portfolio of US$32.8 billion,6 percent(US$2.017 billion)was spent on digital healthrelated investments in 201222.Regionally,Sub-Saharan Africa accounts for the most digital healthrelated investments.The total investments in digital health initiati
216、ves in the region stood at US$1.78 billion.South Asia ranked second.Digital health investments there reached around US$1.05 billion(Table 4),even as the region reported a lower number of digital health interventions relative to other regions.The bulk(84 percent)were foundational investments and func
217、tional investments(Figure 15).The large investments shown for GOV GP in digital solutions may derive from the focus of this global practice on GovTech initiatives aimed at a whole-of-government approach to public sector modernization.HNP GP differed from other global practices in its focus on invest
218、ments in health information systems,while the largest investments of the remaining global practices were in foundational aspects.This shows complementarity among the investments across the four global practices included in this analysis.Of the World Banks total HNP investment portfolio of US$32.8 bi
219、llion,6 percent(US$2.017 billion)was spent on digital healthrelated investments in 201222.The bulk of HNP-managed investments focused on health information systems(51 percent of HNP GP digital health investments).The temporal trends in investment reflect this too:Figure 16 shows that,over time,the m
220、ost significant area of growth in HNP-managed investments in digital health was in health information systems.Figure15 Digital HealthRelated Investments,by Type and Region,201222Figure continued.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE34Figure 15 Digital HealthRelated Investments,by Type a
221、nd Region,201222(continued)Figure16 Changes in Type of World Bank Digital Health Investment Prior to COVID Programs,201120If the investments are broken down by investment subcategory,the greatest emphasis in 201222 was on providing technology infrastructure.A substantial share of the investments und
222、er the HIS category were directed toward the subcategories of analytics,surveillance and disease monitoring,financing,and patient-centric investments(Table 5).CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS35Table5 Number of Projects and Volume of Digital HealthRelated Investm
223、ents,by Subcategory,201222Note:The number of projects here denotes health interventions in a single project mapped to more than one FFF(foundation,functional or frontier).DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE36Disaggregating the results indicates that most of the investments in analytic
224、s were focused on(a)health management information systems;(b)performance and quality dashboards;and(c)location mapping services(Table 6).Table6 World Bank Funding for Digital Health,by Subcategory of HIS-Related Investments,201222Table continued.CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN T
225、HE LAST 10 YEARS37Table 6 World Bank Funding for Digital Health,by Subcategory of HIS-Related Investments,201222(continued)Note:The number of projects here denotes health interventions in a single project mapped to more than one FFF(foundation,functional or frontier).In summary,the World Bank Digita
226、l Health Portfolio Assessment shows that(a)the World Bank has invested substantially in the last 10 years(US$3.962 billion;6 percent of the HNP GP health portfolio),(b)aside from HNP GP,projects managed by several global practices contributed 49 percent of digital healthrelated investments;(c)invest
227、ments have largely been in South Asia and Sub-Saharan Africa;and(d)842 percent of investments focused on the foundational and HIS aspects of digital health investments.Investments in Digital Health by Other Development PartnersThe World Bank met with several development partners to learn about their
228、 experiences in supporting digital health:specifically,information was provided on the nature,volume,and challenges relating to their investments in digital health.Key themes emerging from the discussions are as follows:yAkin to the World Banks historical focus,most digital investments by other deve
229、lopment partners are also focused on health information systems(HISs)and the data HISs produce.The availability of data is the key metric of success of investments in these systems.Typically,investments have been most prevalent for three types of HISs:logistics management information systems,health
230、management information systems,and electronic medical records.Investments in such records are newer and account for most of the more pressing investment needs.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE38 ySome past digital health investments have not led to scaling-up as planned,primarily be
231、cause of overly optimistic expectations,basic infrastructure challenges(lack of electricity and lack of mobile or fixed internet connectivity),the lack of long-term planning,challenges arising from fragmentation,lack of sustainable financing after the initial investment,a lack of government readines
232、s and capacity,lack of norms and standards for interoperability,lack of connectivity and functional IT infrastructure(hardware),and lack of evidence of what works and how it works best.yBeyond information systems,investments have focused on individual digital health interventions,such as mobile appl
233、ications aimed at specific population groups or digital medical devices,such as digital X-ray devices.yThe lack of capacity and digital literacy remain key challenges and hamper the success of digital health investments.As a result,development partners have significantly invested in capacity buildin
234、g in digital health,and coordination efforts are significant.ySuccess in digital health requires good infrastructure and a well-defined health data plan to determine how all the data will be collected and organized.yThere has been mixed success in the engagement with the private sector,and the exper
235、iences of the private sector have been mixed in working with governments on digital health solutions.yOnce a system has been developed,the annual maintenance cost of system operations is higher than expected,at around 30 percent of the total initial upfront investment.These costs have not always bee
236、n included in the initial planning.yIn the future,digital health investments need to focus more on the ecosystem and other foundational aspects,such as digital health governance,instead of focusing exclusively on discrete information systems or discrete digital health interventions.This suggests tha
237、t investments should be focused on interoperability,cloud computing,and other system-level efforts.yDevelopment partner budgets for digital health range from US$50 million a year to US$135 million a year.Concurring with the information in the Digital Health Atlas significant component is in South As
238、ia and Sub-Saharan Africa(as the WHO Digital Health Atlas also shows).CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS39Private Sector Partner Perspectives on Investment in Digital HealthThe private sector plays various roles in the digital health space:it is an innovator and d
239、eveloper of digital health solutions,and those private sector companies that deliver health care are also users of digital health solutions(Figure 17).Figure17 The Opportunity to Engage with the Private Sector on Digital HealthIn a 2023 IFC survey(conducted through LinkedIn and key informant intervi
240、ews),private sector stakeholders(both health care delivery companies that rely on digital health solutions and technology companies that provide digital health solutions)shared their views on using digital technology in health care.Four issues came to the fore:(a)waxing and waning levels of awarenes
241、s about digital health;(b)importance of consistent strategy,financing,and investment;(c)the need for integration and regulation;and(d)under-appreciated challenge of implementation and capacity.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE40a.Waxing and waning levels of awareness about digital h
242、ealth yThere is increasing awareness of what digital health is and what it offers organizations that provide private health services.But digital health is not uniformly understood.Local market conditions directly impact the level of digital health maturity and utilization.yCOVID-19 demonstrated the
243、necessity of digital health.Since then,the urgency of adopting digital technologies,although still acknowledged,has slipped off the radar.yThere is a lack of appreciation of the extent of foundational investments needed(such as connectivity)to make digital health interventions work.yDigital initiati
244、ves are not front of mind for board-level or senior management.Successful adoption requires senior-level ownership.yAwareness about the need for health standards for data exchange,security,data protection,and hardware has increased,but more should be done.b.Importance of consistent strategy,financin
245、g,and investment yAn increasing number of organizations have or are developing digital health strategies,but these have not yet been implemented.Many digital health strategies focus on cybersecurity,telehealth,digital patient administration,electronic health records,data analytics,performance manage
246、ment,and workflow simplification.ySelecting the digital interventions to implement is difficult,as is figuring out how to integrate these interventions into the existing architecture and the identification of the appropriate contract model.yImplementing digital health initiatives is often restricted
247、 by funding challenges.To secure financing,these investments require a clear business case(investment,return,benefit),that is,the value proposition needs to be clear.c.The need for integration and regulation yThe integration with existing systems is a recurring problem in the adoption of digital app
248、roaches in health care,particularly with regard to hardware,connectivity,and data storage.This is a key inhibitor of broader digital health adoption.CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS41Regulation continues to be a constraint on the evolution of digital health in m
249、any markets,although there has been recent positive movement.Regulatory compliance is an area of increasing focus.d.Under-appreciated challenge of implementation and capacity yAccess to implementation skills continues to be a significant barrier to the broader adoption of digital health.The skills i
250、nvestment required for digital health development implementation and successful deployment is a growing need in many markets.yData access is a constant challenge,as is the lack of the ability to analyze the available data given the siloed nature of locations.Skills in analyzing data are a significan
251、t issue because of the skill gap.yPhased digital adoption is being increasingly considered because of funding and capacity constraints.The careful planning of initiatives is therefore required.yThere is a growing realization and expanding focus on the importance of data.Senior management and some bo
252、ards are talking about the widening focus.Senior ownership of the topic and understanding from the top are critical to success.ySome organizations now offer specific big data training to enhance understanding and the awareness of the usefulness.A field study in Kenya affirms these issues:in it,priva
253、te sector vendors have reported that implementation is constrained by funding problems,the prioritization of services,the lack of confidence among users in new technologies,and the lack of appropriate data-sharing policies (Muinga et al.2020).Although this assessment shows that there are specific pr
254、oblems,it also points to opportunities for the public and private sectors to work together with each other and with the public sector in more meaningful and mutually beneficial ways in emerging markets.This will help foster an environment where digital health solutions are affordable,well regulated,
255、integrated,and of good quality and that the solutions can be implemented and financed sustainably.The policy note in Annex C provides more information as to how the private sector might want to approach such options.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE42Digital Health Investments:Persp
256、ectives of Patients and Providerspatient perspectivesIn the last decade,more patients have looked for health information online or interacted with online health services.In Pakistan,over 60 percent of students indicated that they looked for health information online(Tariq et al.2020).In a study of o
257、ver 250,000 people in the United States,the share who had searched for health information online rose from 47 percent to 55 percent in 201118(p .001),whereas the share who had used technology to interact with the health care system more than doubled,from 13 percent to 27 percent(p .001).However,subs
258、tantial variation existed in the degree of adoption across clinical and sociodemographic subgroups,and the assimilation of technologies proved uneven across various subsets of the population.Patient perspectives on digital health are diverse.Both positive and negative perceptions exist(Table 7).The
259、perceptions depend on several factors:age,technological proficiency,level of engagement in technology design,the nature of the health concerns,the level of knowledge and confidence exuded by health care providers,the extent to which evidence is available that technology delivers better health,and th
260、e personal comfort of patients with sharing health data digitally.Table7 Patient Perceptions of Digital Technology and Data in the Health Services They UsePositive perceptions:comfortable with and want more digital servicesNegative perceptions:factors that may make patients reluctant to use digital
261、technology or dataConvenience and accessibility,particularly in the case of noncommunicable disease.Patients appreciate the convenience digital health technologies offer.Telehealth consultations,online appointment scheduling,and digital access to medical records can make managing health easier,espec
262、ially among people with mobility issues or who live in remote areas(Helleman et al.2022).One area specifically mentioned is diseases that require elevated care,such as noncommunicable diseases(European Patient Innovation Summit 2018)The user-friendliness of technology.Some patients find digital plat
263、forms difficult to navigate,which can cause frustration and limit their willingness to engage with digital health systems(Bally et al.2023).Table continued.CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS43Table 7 Patient Perceptions of Digital Technology and Data in the Health
264、 Services They Use(continued)Positive perceptions:comfortable with and want more digital servicesNegative perceptions:factors that may make patients reluctant to use digital technology or dataImprovements in quality of care.Patients have indicated that technology could support their long-term chroni
265、c disease by helping them track their symptoms,actively manage the different manifestations of their condition,collaborate with their medical team on decisions,and find information,knowledge,and support.Reductions in quality of care.Some patients are concerned about the quality of care that they rec
266、eive through digital health services.For example,in telehealth,patients might worry whether their health care provider can accurately diagnose and treat their conditions without a physical examination(Barony-Sanchez et al.2022)Personalization.Patients are excited by the fact that digital health tech
267、nologies may provide personalized care experiences,such as tailored treatment plans based on data analytics(Dohse 2022).Data consent concerns.Some patients have concerns about the privacy,protection and security of their health data.These concerns can impact the level of trust and,consequently,patie
268、nt engagement with digital health systems(Bally et al.2023).Willingness to share data could be increased by ensuring the ability to consent to data use,consumer access to the data collected from them,ethical and regulatory oversight,and ability to delete data altogether(Gupta et al.2023).Hope that d
269、igital technology can minimize the care coordination challenges that patients face.A recent survey in the United States found that patients and would-be patients spend over 8 hours a month coordinating medical care,that they find it overwhelming,and that they delay care because of these care coordin
270、ation challenges(AAPA 2023).Data integration technology should be able to address these challenges.Concerns about the digital divide.The digital divide might hinder vulnerable populations from accessing the health services they need.In many cases,alternatives to digital service delivery were not ava
271、ilable or known to these populations.This is a particular concern to populations in rural areas,persons living with disabilities,and women and children(Kaihlanen et al.2022).Trust in and preference for technology-based solutions.Individuals have varying levels of trust in the use of digital or AI te
272、chnologies for medical care,including diagnosis and treatment.An experiment by Robertson et al.(2023),for example,showed that,in a US setting,vulnerable populations(minorities and older persons)and less well educated persons are less likely to want to receive or trust a diagnosis from AI-driven tech
273、nology that interprets digital radiological images.On the flipside,physicians can influence this outcome.Thus,in the same study,an explanation and recommendation by a physician to use the AI-based device raised the likelihood of use by 48 percent.Lack of interest in technology and low levels of self
274、-efficacy affect the use of technology in health care.Particularly among vulnerable populations that are not used to technology,the desire to apply technology,the belief that one may affect ones own health in a positive way,and the trust that technology might support health may not be as prevalent(B
275、arony-Sanchez et al.2022).There is also a sense of skepticism,and patients need more evidence that technology works(European Patient Innovation Summit 2018).DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE44health Worker perspectivesHealth care provider views of digital health.Based on the limited
276、 information available on the views of health care providers on digital technology,the opinions about investments in technology for health care delivery are mixed(Table 8).This conclusion is echoed in a survey of health care providers on telemedicine services that the World Bank conducted in the Mal
277、dives to assess the readiness for telemedicine applications.While providers were supportive of such an innovation,they also expressed reservations about the preparedness of health care facilities to add telemedicine as a service.Table8 Technology in Health Care:Advantages and Disadvantages from the
278、Perspective of Health Care ProvidersAdvantagesDisadvantages Harmonize out current conflicts between the increasing marketization of health care systems and professional ethical demands(Lenz 2021).Create a deeper doctor-patient relationship(Gyrffy et al.2020).Telemedicine may reduce costs(Wernhart et
279、 al.2020).Addressing patient autonomy,time and resources savings,and health and behavior change promotion is premature.More research is warranted that focuses on reducing barriers,minimizing disadvantages,and assessing the clinical value of commercially available digital health technologies(Tomasell
280、a and Morgan 2021).Improved efficiency and effectiveness at work that benefit the patient and the institution(Sau et al.2019).Empowering patients who value their independence(Nakrem et al.2018).It may undermine the demand for medical autonomy,a central element of the medical ethos(Lenz 2021).Uncerta
281、inty about whether the data can be trusted and uncertainty about the reliability of the data Wernhart et al.2020).Concern about the unknown ways in which technology could change the doctor-patient relationship if the patient has access to the same data at the same time as the doctor(Gyrffy et al.202
282、0;Wernhart et al.2020).Barriers related to the loss of time in clinical visits because of technical issues,the lack of IT support,the lack of confidence in IT skills and knowledge,and the inability of patients to access technology(Sau et al.2019;Zaresani et al.2020).Civil Society Views on technology
283、 accessPerspectives on digital access.A 2023 study led by Connect Humanity involving 7,500 civil society voices in 136 countries identified large gaps in technology access,content,and skills.The survey results indicate that it is too expensive to access the internet,that the digital skills required
284、to participate are lacking,and that security is a concern,that is,feeling safe to participate in the public forum offered by the internet.“Taken together,this means that we are excluding our most vulnerable community members from civic discourse,access to jobs,and the ability to be in virtual fellow
285、ship with others who share common interests”(Connect Humanity,2023,4)CHAPTER 3 LOOKING BACK:DIGITAL HEALTH INVESTMENTS IN THE LAST 10 YEARS45Perspectives on digital health efforts.Van Stam(2022)has collected the perspectives of community stakeholders in Africa on digital health investments and found
286、 the following:yThe need to support foundational infrastructure:“We are devising nice ideas that we cannot implement,because the underlying infrastructure is not there”(Van Stam 2022,664).yThe need to address fragmentation and siloed systems:“Many donors support the health sector.The tendency has be
287、en mainly siloed data systems,siloed implementation.In most cases,these are not really interoperable,with even national systems.As a result,the health sector struggles with a lot of siloed implementations,which is mainly driven by donor funded initiatives”(Van Stam 2022,665).yImportance of collectiv
288、e development and human-centered design:“A sustainable e-health solution is best designed and developed organically and interactively with stakeholders within the context and setting in which it will be applied and in alignment with the existing health,education,and technology enterprises”(Scott and
289、 Mars 2013,2).yUse technology to solve actual health problems:“We talk about it,but,in an African country,for instance,as in many other countries,I havent yet seen a single digital service that I think is useful.I have not seen any digital health service that is there and is working for the people”(
290、Van Stam 2022,666).yCultural relevance and equity:“Equity comes into play;if we adopt digital health or any technology for that matter we must scan the landscape,look at the communities:what do they want and what do they lack for them to be digital?Ignorance comes into play when we come in with tech
291、nologies and ignore the cultures of the areas,we ignore the configuration of the communities.this will result in technologies not really being embraced by communities”(Van Stam 2022,666).There is remarkable coherence in the perspectives of the private sector,patients,providers,and the community on w
292、hat should be improved to unlock the value of digital health for everyone:Expand foundational infrastructure;address fragmentation,interoperability,and integration;design with the participation of individuals to ensure relevance and encourage use;build digital skills and awareness;improve regulation
293、s to ensure trustworthiness;focus on technology that solves health sector problems;make the case for why it is valuable to ensure continued funding;and guarantee data protection and privacy.These aspects should be given careful consideration in future investments to embed digital technology and data
294、 as an integral part of health service delivery and health systems.47Chapter 4Looking Forward:a Digital-in-Health FutureThe advance of technology is based on making it fit in so that you dont really even notice it,so its part of everyday life.”Bill Gates“DIGITAL IN HEALTH:UNLOCKING THE VALUE FOR EVE
295、RYONE48Key Messages in this Chapter yThe perfect storm of opportunity for the next wave of transformation in health care through personalization,technology take-up and scale,and person-centered approaches is here.The time to act is now.yWhat does the future of health care look like?The future of hea
296、lth is infused with embedded technology and data in a way that is both invisible and that enables preferred,personal,preventive,and predictive health care to be accessible to everyone when and as they want it.yThis requires a cultural,organizational,and behavioral evolution of health care service de
297、livery and health care system management that typically evolve through three stages,from digitalization to digital for health and to digital-in-health.yDigital-in-health means considering the digital aspects of every part of health care delivery,public health,and health system management:how to desi
298、gn them and how they work together to create a health digisphere in a country.Every countrys health digisphere will be different and unique to that countrys health system context,opportunities,and challenges.This chapter looks forward to the future of digital technologies in health and health care.I
299、t describes the latest advances in digital technology and what that means for health.And,it defines the concept of digital-in-health,which is a mindset change that is needed for countries to unlock the value for everyone.Advances in Digital Technology for Better HealthHealth care is entering a perio
300、d of profound and accelerated change.Much like the human body,health systems are involved in continual waves of change:cycles of organic growth,adaptation,stagnation,apoptosis,and renewal.The change has been accelerated by the disruptions of the COVID-19 pandemic.The changes facing the health sector
301、 are beyond the notion of a new technology or digital solution to digitize an existing process:more profound than that,the changes brewing in the health sector are existential in nature-person-centered health care,embracing new medical and health discoveries,the integration of previous separate disc
302、iplines an expanded understanding of what is necessary to live life well.Health care is set to transform into CHAPTER 4 LOOKING FORWARD:A DIGITAL-IN-HEALTH FUTURE49a system thats centered around the patient,focusing on virtual and at-home treatments as well as linked outpatient care.Driven by data a
303、nd analytics,it will prioritize value and bear risks while embracing transparency and interoperability.Enabled by cutting-edge medical technologies,it will become an integrated yet fragmented system.(Singhal et al.2022).The period of change will be characterized by a democratization of health care a
304、nd a cultural transformation in how health is delivered and perceived.Technologies that are disruptive yet provide accessible,digital,and factual data to both patients and caregivers will trigger a shift in health care culture.This change will be characterized by an equitable relationship between do
305、ctors and patients,mutual decision-making,and a more democratized approach to healthcare(Mesko et al.2017).It will also be characterized by rapid technological advances not previously seen in a generation.Figure 18 shows the key areas of expansion already underway,recognizing that these trends repre
306、sent only a glimpse of the mushrooming field of digital technology in health.One of the main areas of rapid advancement,is in generative artificial intelligence,or genAI,described in Box 1.Figure18 Burgeoning Applications of Digital Technology in Health and Health CareDIGITAL-IN-HEALTH:UNLOCKING THE
307、 VALUE FOR EVERYONE50Box 1 The revolutionary opportunity(and risk)associated with Generative AIIn the world of artificial intelligence(AI),November 2022 was a watershed moment.The launch of chat generative pretrained transformer(ChatGPT)by Open AI sparked a flurry of unprecedented activity in a spec
308、ific kind of AI,namely,generative AI.Generative AI is a sophisticated way of(a)predicting the next likely sequence of words or image pixels from a set of images or words and(b)pre-training a model on a large dataset so that it does not need to re-train itself every time that it is presented with new
309、 query.This makes it seem as if AI can generate text or images.The two main new categories of tools are advanced AI-based conversational software and image generators.First,the new generation of conversational software(initially,mainly chatbots),such as Open AIs ChatGPT and Googles Bard.ChatGPT,like
310、 many of its peers,is a conver-sational software chatbot,which is a computer program that responds to a question(or prompt).What is special about it is that it uses advanced data analytics called neural networks and a vast amount of publicly available data to formulate its responses.Because ChatGPT
311、and other similar generative AI tools have been specifically set with a certain level of randomness,the same question will yield different responses every time.The generative pretrained transformer relies on algorithms that were already trained in language structure on large datasets,and,so,it does
312、not need significant new data for further prediction.It is the generative AI analytical engine that has such potential for health care and health systems,especially if is has been trained on medical texts and images and has a foundational medical language in which it can communicate.Second,AI image
313、generators,including Dall-E and Stable Diffusion,represent another family of genAI software that can generate original images from scratch once the image has been described in words or it can extract text from images.Thus,it can interpret images and explain them in words or create images based on wo
314、rd descriptions.These technologies have application potential in the health sector,particularly because the analytical engines that underpin generative AI tools are pointed inward using health records and other medical data.Applications require careful thought.These tools can augment the efforts of
315、health workers and health system managers and streamline how services are provided.So,they are augmented intelligence tools rather than artificial intelligence tools.Three specific areas in which early adoption is most likely,particu-larly in low-and middle-income countries,are all related in some w
316、ay to the summa-rizing of information,as follows:yJoining,summarizing and querying various types of disconnected health records.One can use these tools to read,interpret,summarize,and query a wide variety of medical records that are in systems that are not interoperable or even in the same format.In
317、 this example,30 pages of different types of medical records from Continued.CHAPTER 4 LOOKING FORWARD:A DIGITAL-IN-HEALTH FUTURE51one patient(from an EKG readout to prescriptions to a doctors clinical notes to a patients self-completed medical history)was summarized in a one page clinical summary by
318、 the generative AI tool in a matter of seconds.And,in this example,a generative AI model is used to extract medical data from a variety of PDF files and handwritten documents through a query function.This family of AI tools can immediately help solve the conundrum of legacy systems and combinations
319、of paper and digital medical records.ySupporting clinical decision-making,specifically among front-line workers and in areas of health care with more repetitive functions like in radiology.(There is an acute shortage of radiologists in low-and middle-income countries.)Rajpurkar and Lungren(2023)show
320、 how generative AI tools may be used to collect and summarize inputs from radiologists,physicians,the AI tool,and a patients medical records to support more highly informed choice(Figure 19).Lang et al.(2023)published the results of one of the first-ever randomized control trials comparing AI and ra
321、diologists.In their prespecified clinical safety analysis,Lang and colleagues show how AI assisted screening detected breast cancer at the same rate as standard double readings by radiologists working in pairs,and simultaneously reduced the screen-reading workload of radiologists by an impressive 44
322、%.The authors concluded that AI-based breast cancer screening was safe.Figure19 Use of Generative AI in RadiologySource:Rajpurkar and Lungren 2023Box 1 The revolutionary opportunity(and risk)associated with Generative AI(continued)Continued.DIGITAL-IN-HEALTH:UNLOCKING THE VALUE FOR EVERYONE52 yAccur
323、ate and conversational medical chatbots as entry points to health care.COVID-19 unleashed a rush in many countries to set up telemedicine services.If medically accurate chatbots were available for initial triaging and trusted by the public and providers,they could make telemedicine more effective.A
324、medical chatbot could perform the first level of triage,prior to referral to a health facility(if needed).This would make medical chatbots the future entry points to health care.Because these generative AI solutions are pretrained,they do not require large datasets,complicated machine learning,or hi
325、gh-level skills to operate.This significantly reduces the barrier to entry in low-and middle-income countries.However,with promise comes potential peril.There are real challenges that need urgent answers and many of these apply more broadly to AI systems beyond generative AI:yRegulation.Medical devi
326、ces that use AI to derive(potential)diagnoses or recommend treatments need to be subject to rigorous regulatory processes akin to pharmaceutical approval processes(regulation either as medical devices or as medical products).Such regulatory systems are nascent in many low-and middle-income countries
327、.Regulatory mechanisms should also include human-in-the-loop(HITL)principles to implement practices that allow for humans to have oversight for validating models and removing the black box nature of AI models(Buckley,2021).yTrust.These tools will only enjoy widescale use if they are trusted and valu
328、ed as an integral part of the health care delivery network,augmenting the work of health workers,making their jobs easier and allowing them more time with patients:augmented intelligence for health workers and clients of health systems.yData protection.Patient privacy will be more at risk than ever
329、in what could be a rush to bring all the disparate medical data together.Its important to ensure that personal data is used only for limited and identifiable legitimate purposes,that only that data which are necessary for the purpose are collected/processed,that data subjects have certain rights ove
330、r their data,and that data collectors/processors have certain obligations in how they handle personal data yKnowing whos who in a health system.Without unique identifiers that enable medical records to be linked to individuals and across locations where the individuals received health care,usefulnes
331、s will be limited.yBias.The bias in AI systems and the ethics surrounding the development and use of these systems has been a long-standing debate and generative AI solutions are not exceptions to these issues.Addressing bias in AI systems will require continuous Box 1 The revolutionary opportunity(
332、and risk)associated with Generative AI(continued)Continued.CHAPTER 4 LOOKING FORWARD:A DIGITAL-IN-HEALTH FUTURE53research in understanding and removing bias,regulatory mechanisms to establish responsible processes for mitigating risks,medical education(Arora and Arora,2022)and improving access to re
333、presentative and high-quality health data.yNarrowing the digital divide.The more rapidly new technologies are introduced,scaled up,and used,the narrower the divide between these tools and the versatility of many health care systems in low-and middle-income countries.In considering the potential of AI,climate dimensions should also be considered.There is a growing dialog on the awareness of climate