Sustainability: Digital Health’s Biggest Challenge

Kate Plourde, MPH

FHI 360 | Technical Officer, Research Utilization
A group of data collectors snap a quick picture as they work to find rural villages in Northern Nigeria.

A group of data collectors snap a quick picture as they work to find rural villages in Northern Nigeria. © 2013 eHealth Africa, Courtesy of Photoshare

A common theme throughout the 2016 Global Digital Health Forum (GDHF) was sustainability. From the opening panel, through almost every session and hallway conversation, to the closing plenary, sustainability was a major topic of discussion. And, it seemed that each conversation almost always led to the same conclusions:

  1. In the digital health community, we know very little about successful approaches to program sustainability.
  2. We do know that identifying such approaches will require disruptive thinking.
  3. Members of the digital health community are ready to take on the challenge.

The potential benefits that digital health offers—the ability to reach large numbers of people at a low cost with critical health information, confidentially engage marginalized populations, improve data collection and reporting accuracy, facilitate task-shifting to lower-level health care workers, reduce transportation barriers, and so many more—are undisputable. However, like in all sectors of international development, no matter how promising a programmatic approach is, the funding will not last forever. As the digital health community continues to innovate, global access to mobile phones and other digital tools increases, and programs continue to adopt digital approaches, identifying successful approaches to program sustainability becomes even more imperative. Yet, to date, we know very little about how to do this.

“Aid dependency” is not a new phenomenon, and it is certainly not unique to digital health. Breaking this cycle requires a different approach to development; identifying such an approach (or approaches) requires disruptive thinking. It’s possible that the disruptive nature of digital health may somehow inherently lend itself to sustainability, but more likely, the disruptive and creative thinking of the digital health community will lead us there.

Many of the organizations that participated in the 2016 GDHF are already pushing boundaries. There was a lot of talk at the conference about revenue-generating approaches. Some organizations have considered selling program-use data to the private sector, allowing for a steady revenue stream that could potentially support ongoing program implementation. Despite the fact that the data would be de-identified, this approach is loaded with controversy, and some question its ethicality. Some organizations are considering selling advertising space—an approach that appears a bit more palatable to the larger community. Others, including the m4RH team at FHI 360, have explored the potential to shift costs to the end user, either by requiring users to pay or by creating some sort of tiered payment system whereby only those who can afford to pay for services. The m4RH team found that almost half of m4RH users in Tanzania and approximately one-third of users in Kenya were willing to pay for the service. However, without a tiered system, it is likely that the cost, even if it is minimal, may deter those who most need the service from accessing it. Finally, some groups, like Dimagi, are using product revenue to invest in and maintain their core product.

Identifying solutions for financial sustainability may be easier if we can reduce program costs. In many of the countries where we work, mobile data is less expensive than SMS. This has prompted organizations to move away from SMS-based programs toward those based on social media platforms or digital applications. However, many of our programs’ target populations still do not own smartphones, despite rapid ownership growth. So, at least for the time being, SMS may still be the most appropriate delivery channel in some cases.

Other organizations, like Village Reach and Human Network International, have successfully engaged cellular telephone companies to subsidize or discount program costs. Some companies offer exclusive access to health content to attract customers to their brand, while others support programs as a corporate social responsibility activity. Notwithstanding a few successful partnerships, there remains a limited level of support from the industry. One issue may be that programs often seek to engage the private sector once the intervention is already developed, rather than during earlier development stages. As we continue to push the digital health field forward, we need to identify opportunities to work together with the private sector to better meet the needs of our respective priority populations.

Even though digital health is still a relatively young field, it sometimes seems as though our position as innovators means we receive extra pressure to identify pioneering solutions for program sustainability. But this pressure, present or perceived, isn’t unwarranted—the same disruptive thinking that led to the emergence of digital health and continued innovation in our field is necessary to break the cycle of aid dependency. Based on what I heard in the plenaries, presentations, and passageways, it seems like the digital health community is up for the challenge.