Table 3

Factors influencing scale and sustainability of digital tools for front-line health workers (FLHW) in India

FactorsScaleSustainability
Digital health solution characteristics
 Perceived valueThe solution responds to the needs of various actors.
Example:
  • FLHW data capture and decision-support solutions streamline data collection systems and improve the timeliness, quality, accessibility and use of data.

  • Direct to FLHW solutions affordable, standardised and logistically simple mechanism to refresh face to face training and fill in knowledge gaps.

  • Institutionalises support, supervision, and performance monitoring.

  • For FLHW data capture and decision-support tools, the solution should move beyond data capture for report generation to use of data at multiple levels of the health system to improve provider performance and quality of service delivery.

 Adaptability
  • Configurable software is seen as a more scalable approach which can accommodate differences in state-level health programmes and priorities.

  • Extensibility is driven by infrastructure and telecommunications connectivity choices.

  • Desired configurability to allow for changes over time (eg, addition of new curriculum for Mobile Academy; NCD content added to TECHO+).

 Data storage and governance
  • Use of high-quality cloud-based data storage (eg, Mobile Academy).

  • Features of data governance, including data privacy, access, consent, not considered to be a key enabler of scale.

  • Failure to prioritise data governance features have likely had adverse consequences on consent capture at the front lines.

  • Data governance largely not considered, but understood by some as concerning.

  • Evolving data protection legislation is likely to have impact on data capture, procedural access controls, and consent processes.

Actor roles and relationships
 Government champions
  • Champions in influential government ministerial positions were vital to successful scale-up

  • Communication between state government actors important

    • Example: NCD app and Mobile Academy were first implemented in one state with support from senior actors in that state’s government, who praised the programme when interacting with other states, thus creating champions in other states.

  • Sustained engagement from influential government actors critical.

  • The movement (due to transfer, retirement, other) of these champions is a significant barrier to sustainability.

  • NDHM would also be a factor in enabling sustainability—so not an individual champion but a government champion if you will.

 Stakeholder networksImportant to scaling digital tools for FLHWs
Example: A government champion pushing CAS forward to approve decision to scale.
Argued as key to longevity of digital tools for FLHWs
Example: For Mobile Academy, importance of cultivating deeper relationships going down to all implementers/FLHWs and broader buy-in to ensure the programme continues when there is turnover of key individuals. Or the NCD one that allows for adding other services.
 FLHW engagementFLHWs are supported to use technologiesContinuous FLHW engagement and feedback is integral to the longevity of the digital tool
Example: FLHWs value and demand the tool, and want it fixed if it breaks or crashes.
Implementation processes
 Investing in evidenceFormative research used to design solutions
Example: Some cases underwent extensive user testing and embedded development (MA, NCD app, TECHO+), while others were first developed by technology partners with specifications/data capture features stipulated, and then adjusted when implemented (ANMOL).
  • Evidence linking digital solutions to changes in health outcomes (impact) reported to be desirable.

  • Routine use of system generated data seen as integral to demand creation and learning from evidence.

 Operationalisation
  • Programme roll-out fosters FLHW engagement and ensures digital tool addresses FLHW needs

  • Varied perspectives on whether to discontinue use of paper records immediately, or in phases.

  • Procurement processes are initiated at the outset of the programme versus at the point of transition to government.

  • Programme roll-out fosters FLHW engagement and ensures digital tool addresses FLHW needs

  • Procurement processes are initiated at the outset of the programme versus at the point of transition to government.

 Evolving stakeholder roles and relationships
  • Initial donor investment integral to enabling scale.

  • Programmatic adaptations may be required to conserve finite resources.

  • Concerns about government capacity to ensure handovers.

  • Government funding is important but not necessarily sufficient for sustainability, as even with government funding, programmes could still be cancelled.

Context
 National-state dynamics
  • Standardised model for national-level to state-level scaling up does not exist.

  • Several notable examples of state-level solutions which have scaled.

  • National government leadership in establishing standards for interoperability.

Requires more robust data governance in long term
Example: The national government could create an ecosystem and standards within which states can innovate. If this standardisation is in place, each state can have its own system using a common API and all the systems can speak to each other and state level data can be fed into a central database.
 InteroperabilityIntersectoral collaboration between government ministries required to reach agreement on common architecture and standards for interoperability.
  • Intersectoral collaboration between government ministries required to reach agreement on common architecture and standards for interoperability.

  • Need to mandate adherence to standards once agreed on

    Example: It is important to ensure that all digital platforms built by all Ministries are interoperable with each other to eradicate siloed approaches to the delivery of healthcare, nutrition and other social services.

  • NCD, non-communicable diseases; NDHM, National Digital Health Mission.