Table 2

Lenses and levels for examining drivers of digital health

Health systems drivers with a governance focusHealth system levels
MacroMesoMicro
Service delivery lens

  • Policy mandate

  • Coordination mechanisms

  • Service delivery readiness

  • User capacity

  • Policies on privacy of personal data, interoperability, procurement, etc

  • Network coverage: cell phone towers

  • Composition and organisational location of task force

  • Technology design choices

  • Network coverage: mobile network operator verification systems

  • Health worker workload

  • Financial resources to support the programme

  • User mobile literacy, access and ownership

  • Network coverage: SIM turnover, handset type and functionality

Society lens

  • Political prioritisation

  • Accountability dynamics

  • Interpersonal dynamics

  • Trust in government or private companies maintaining information responsibly

  • Incentives and positionality of implementing partners (Ministry of Health, technology partners, mobile network operators, academic/research partners)

  • Stakeholder relationships: NGOs with prior positive relationships with government more able to present data with negative findings to government

  • Health worker responses and prioritisation

  • Women with culture of concealing pregnancy, not being aware that they would be receiving SMS, can distrust or be jeopardised by text messages from unknown numbers

  • DRC: more men than women accessing digital app on family planning originally targeted for women; is male power reinforced vs transformed?23

Systems lens

  • Dis/equilibria

  • Feedback loops

  • Eventuality of change

  • Emergence

  • Path dependence

(Dynamics can link across micro, meso and macro levels)

  • Tanzania: trained enumerators using smartphone apps in people’s homes was a trigger for conversations and relationship building… community validation meetings where people discussed results offline and local health workers present who saw it as an opportunity to channel demands upwards to district authorities for resource allocation decisions24

  • South Africa: health workers adapting registration processes from individual to batch registration; increases numbers of people registered, decreases waiting time for services, but uncertain consent procedures83

  • Nigeria: women promised recharge cards to elicit participation, but then not all tech partners agreed, backfired against women who responded but belonged to these excluded tech partner networks… women then deleted messages and refused to participate24

  • DRC, Democratic Republic of Congo; NGO, non-governmental organisation.