## insea2023004 - Introduction

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---

### Overview
- Discusses, through selected country case studies, how digital health records and telemedicine can improve delivery quality, access to underserved populations, and resource utilization in health care.
- Shows how digital disease surveillance tools can identify outbreaks and track the spread of diseases, while novel digital platforms can facilitate patent licensing and international pooled procurements for better drug access in developing countries.
- Emphasizes that ensuring the safe and well-regulated collection and use of health care data, and facilitating standardization and interoperability of digital infrastructure in different sectors, is critical for success.
- Positions the note within IMF Fiscal Affairs Department’s broader agenda on public finance and govtech (Amaglobeli and others 2023).

### Digitalization concepts and frameworks
- Maps digital health care interventions to spending adequacy, spending efficiency, and fiscal sustainability used to assess macrocriticality of health care and social spending (IMF 2019).
- Describes the “Internet of Health Care Things” structured around three layers (Kelly and others 2020):
  - (1) perception—the use of devices that can perceive changes in an environment (radio frequency identification, infrared sensors, cameras, GPS, medical sensors, smart device sensors);
  - (2) network—data communication and storage (for example, 4G cellular networks, cloud servers);
  - (3) application—interpretation of health data and delivery to the user (for example, use of artificial intelligence [AI] to enhance diagnostic capability, treatment decisions, and disease management).
- References the World Bank’s Framework for the Economic Evaluation of Digital Health Interventions (Wilkinson and others 2023) as a standardized approach for determining and using evidence on the economic value of digital health interventions.

### Empirical evidence from developing countries
- Indonesia:
  - Transition from manual in-kind food assistance to an electronic voucher improved the quality of food received and reduced poverty significantly.
  - Administrative costs are estimated at about 4.1 percent of the total benefits of switching to electronic vouchers (Banerjee and others 2023).
- Niger:
  - Beneficiaries of a mobile cash transfer program increased household and child diet diversity by 9 to 16 percent, and children ate a third more of a meal per day (Aker and others 2016).
- Brazil (e-voting):
  - Adoption of electronic voting technology led to increased utilization of health services (prenatal visits) and improved newborn health from less educated mothers (Fujiwara 2015).

### Using Electronic Health Records (EHRs) to inform policy and care
- Value and uses:
  - EHR data can inform diagnostics, monitor diseases and health security at local, national, and global levels, and provide evidence for resource allocation decisions.
  - Well-organized health information systems allow timely access to patient data and medical history for health care professionals.
- Government support priorities:
  - Ensure that collection and use of health care data are safe and well regulated.
  - Facilitate standardization and interoperability of digital infrastructure initiatives across sectors.
- Estonia case study:
  - Estonian National Health Information System operational since 2008; all citizens have EHRs, transitioning from a paper-based system.
  - E-ambulance and e-prescription programs use the patient’s identification (ID) card; 99 percent of prescriptions are digital.
  - An estimated 15 to 17 percent of prescriptions get changed after drug-interaction warnings are displayed in the e-prescription database.
  - Digitized transactions provide massive data for decision making and allow patients access to their own health data.
- Digital disease surveillance examples:
  - Integrated Disease Surveillance Project in India; Electronic Disease Early Warning System in Yemen.
  - Ghana: Integrated Disease Surveillance and Response system.
  - Kenya: Health Information System (Gray-Lobe and others 2022).
  - Rwanda: Health Management Information System (Mamuye and others 2022).
- Korea case study:
  - Single-payer mandatory health insurance registers all citizens upon birth; the health insurance number links with the national identity system and functions as a key identifier (Jung 2021).
  - A “DNA” (Data, Network, and AI technology) strategy created a special taskforce for digital health (2017); legal amendments during the pandemic allowed collection of data from banks, telecom firms, and surveillance cameras for contact tracing.
  - New data protection laws make pseudonymized data available for scientific research without consent.
  - In 2021 the government launched the My HealthWay app as a mobile-based public personal health record service (Lee 2022); My HealthWay integrates medication and vaccination data, can be linked to Samsung Health and Apple HealthKit, and is interoperable with EHRs in hospitals offering core primary health care functions.

### Expanding access through telemedicine
- Rationale:
  - Telemedicine helps address scarcity and uneven distribution of quality health care services, especially in rural and remote areas.
- Brazil:
  - 1988 constitution established health as a universal right and created the Unified Health System (SUS).
  - Life expectancy rose from about 65 to 75 years in 2019 (UNDESA 2022).
  - Telemedicine legislation emerged in 2000 and was implemented in three phases; the ministry of health developed e-SUS software to integrate systems within SUS.
  - Rapid growth in adoption evidenced by an increasing number of primary care units using digital records and more laptops and tablets used by health professionals (Brazilian Network Information Center and others 2021).
- China / Ping An Good Doctor:
  - Ping An Good Doctor allowed virtual patient–doctor consultations; by 2019 it had 315 million total registered users.
  - Used big data cloud services to provide knowledge support to nearly 50,000 clinics and 100,000 pharmacies and thousands of other health providers.
  - Using data from more than 530 million online consultations, Ping An created an AI doctor; Ping An estimated a five- to tenfold rise in platform capacity thanks to the AI system (Chan Kim and others 2021).
  - In 2019 the Chinese State Council included internet health care in public health insurance reimbursement plans.

### Digital health in sub-Saharan Africa: infrastructure and constraints
- Opportunities:
  - Digitalization interventions (telemedicine, mHealth, eHealth) can help mitigate shortages of health care professionals and infrastructure and improve service coverage and quality for underserved populations.
  - Biometric identification systems are increasingly being invested in to enable data-heavy interventions and facilitate coordination across health, social protection, and education systems (Parekh 2020).
  - Integrated health information systems can increase data collection for decision making (Holly and others 2022).
  - Example innovation: The African Drone and Data Academy in Malawi educates students on drones and data; drones transport blood between clinics (Holst and others 2020).
- Barriers identified via interviews with digital health experts from 10 countries:
  - Weak leadership and coordination.
  - Underinvestment in basic infrastructure.
  - Weak information systems to support data sharing and interoperability.
  - Insufficient stakeholder engagement (Holly and others 2022).
- Importance of documentation:
  - Successful digital health interventions and their challenges should be well documented to support sustainable funding and scaling.

### Digital platforms for patent licensing and pooled procurement
- Medicines Patent Pool (MPP):
  - Established in 2010 in Geneva to improve patented drug access in developing countries by building a transparent drug patent database and sharing licenses online.
  - Systematic study of the HIV drug supply in 103 developing countries found the MPP increased generic drug supply by 7 percentage points (Wang 2022).
  - From 2010 to 2017, the total operating cost of the MPP ($33 million) was much smaller than the estimated consumer and producer surplus: $0.7 billion and up to $181 million, respectively (Wang 2023).
  - MPP is a key partner of the COVID-19 Technology Access Pool and helps construct technology transfer hubs.
- Global Fund pooled procurement:
  - The Global Fund Price and Quality Reporting database (wambo.org) provides buyers access to procurement channels, including the Global Fund’s Pooled Procurement Mechanism (PPM).
  - PPM allows countries to pool drug orders into larger volumes for better discounts and enables buyers to track order status, enter data directly, and enhance reporting and monitoring.
  - Research found the PPM reduced delivery delays but increased procurement lead times needed for advanced planning (Wang and Zahur 2022).
- Note: It can be challenging to disentangle the effects of digitalization from the impacts of pooling because digital platforms are integral to the institutional design.

### Global digital health repositories and knowledge sharing
- WHO Digital Health Atlas (DHA):
  - Global technology registry platform to coordinate digital health efforts and strengthen the value and impact of digital health investments.
  - Provides a standardized format for stakeholders to access, report, and share information on digital health projects.
  - As of February 2023, the DHA had 944 projects registered, reaching about 4.74 million health workers and more than 1.56 million facilities.
- UNICEF Digital Health Centre of Excellence (DHCE):
  - Established in 2021 to support UNICEF’s Digital Health & Information System unit and WHO’s Digital Health and Innovation Department.
  - Provides technical assistance on development and scale-up of digital health solutions, including drug purchases and delivery, service delivery and management, epidemiological surveillance, and workforce training.
  - By January 2023, the DHCE had provided 38 technical assistance engagements of 11 types to 58 countries.
- World Bank and 3ie evidence gap map:
  - Categorizes studies by intervention types and associated health, economic, and behavior outcomes (World Bank and 3ie 2019).
  - Finds ample literature on interventions directed at health care clients and providers, but a considerable evidence gap on interventions related to health system management and data services.

### Conclusion and implications
- Key findings on digitalization and health interventions:
  - Increasing public and private investment in digitalization has resulted in broader use of digital health interventions to improve data quality, public service delivery, and market efficiency.
  - Literature review and country case studies revealed promising impacts of digital health interventions, but questions remain on how to maximize impact while investing in foundational health and connectivity infrastructure, and managing privacy concerns.
  - More comprehensive data and research are needed to untangle effects from digitalization itself from expanded access to existing healthcare services, and to understand the cost-effectiveness of different interventions.
- International coordination and initiatives:
  - Institutions like the MPP and the PPM have used digital tools to improve the licensing, purchasing, and delivery of drugs to developing countries.
  - Major health international organizations like the WHO and the United Nations have been refining open access global repositories to enhance information sharing, standardization, coordination, education, and technical support.
- Implications for IMF engagement and macrocritical health issues:
  - High-level policy insights on digitalization and health care could support IMF engagement with country authorities on macrocritical health-related issues.
  - IMF country teams have become increasingly engaged on health spending issues in surveillance and program work—and more so during the COVID-19 pandemic (IMF 2019, 2023).
  - Digital interventions might help address macrocritical health care issues related to:
    - Spending adequacy (for example, increasing access to health services for underserved populations with remote service delivery).
    - Efficiency (for example, using digital health records to ensure timely access to medical data).
    - Sustainability (for example, drawing evidence-based insights from digital interventions to ensure sustainable financing and service continuity).
- Table 1 — Summary of Country Cases (selected challenges and digital solutions):
  - Challenge: Access to remote and rural areas
    - Country cases: Brazil and sub-Saharan Africa
    - Digital solution: Telemedicine, access to laptops and tablets, data, and drones
  - Challenge: Transferability of records
    - Country cases: Estonia
    - Digital solution: Centralized standard e-patient portal
  - Challenge: Interconnectivity, geolocation, and tracing
    - Country cases: Korea
    - Digital solution: Integrated centralized insurance system with other data, and mobile-based health records
  - Challenge: Access to quality health care
    - Country cases: China
    - Digital solution: Umbrella health care provider and AI doctor

*Source: insea2023004 - Introduction; Source: IMF Note NOTE/2023/004*

### Introduction ...........................................................................................................

### insea2023004 - Introduction

### Overview
- The note discusses, through selected country case studies, how digital health records and telemedicine can improve delivery quality, access to underserved populations, and resource utilization in health care.
- It shows how digital disease surveillance tools can identify outbreaks and track the spread of diseases, while novel digital platforms can facilitate patent licensing and international pooled procurements for better drug access in developing countries.
- Ensuring the safe and well-regulated collection and use of health care data, as well as facilitating standardization and interoperability of digital infrastructure in different sectors, is critical for the success of these interventions.
- The note fits into IMF Fiscal Affairs Department’s broader agenda on public finance and govtech (Amaglobeli and others 2023).

### Digitalization concepts and frameworks
- The IMF maps digital health care interventions to the concepts of spending adequacy, spending efficiency, and fiscal sustainability used to assess macrocriticality of health care and social spending (IMF 2019).
- The “Internet of Health Care Things” is structured around three layers (Kelly and others 2020):
  - (1) perception—the use of devices that can perceive changes in an environment (radio frequency identification, infrared sensors, cameras, GPS, medical sensors, smart device sensors);
  - (2) network—data communication and storage (for example, 4G cellular networks, cloud servers);
  - (3) application—interpretation of health data and delivery to the user (for example, use of artificial intelligence [AI] to enhance diagnostic capability, treatment decisions, and disease management).
- The World Bank’s Framework for the Economic Evaluation of Digital Health Interventions (Wilkinson and others 2023) provides a standardized approach for determining and using evidence on the economic value of digital health interventions.

### Empirical evidence from developing countries
- Indonesia: Transitioning from a manual in-kind food assistance approach to an electronic voucher improved the quality of food received and reduced poverty significantly; the administrative costs are estimated at about 4.1 percent of the total benefits of switching to electronic vouchers (Banerjee and others 2023).
- Niger: Beneficiaries of a mobile cash transfer program increased household and child diet diversity by 9 to 16 percent, and children ate a third more of a meal per day (Aker and others 2016).
- Brazil (e-voting): Adoption of electronic voting technology led to increased utilization of health services (prenatal visits) and improved newborn health from less educated mothers (Fujiwara 2015).

### Using Electronic Health Records (EHRs) to inform policy and care
- Value and uses:
  - EHR data can inform diagnostics, monitor diseases and health security at local, national, and global levels, and provide evidence for resource allocation decisions.
  - Well-organized health information systems allow timely access to patient data and medical history for health care professionals.
- Government support priorities:
  - Ensure that collection and use of health care data are safe and well regulated.
  - Facilitate standardization and interoperability of digital infrastructure initiatives across sectors.
- Estonia case study:
  - The Estonian National Health Information System became operational in 2008; since then all citizens have had EHRs, transitioning from a paper-based system.
  - E-ambulance and e-prescription programs use the patient’s identification (ID) card; 99 percent of prescriptions are digital.
  - An estimated 15 to 17 percent of prescriptions get changed after drug-interaction warnings are displayed in the e-prescription database.
  - Digitized transactions provide massive data for decision making and allow patients access to their own health data.
- Digital disease surveillance examples:
  - Integrated Disease Surveillance Project in India; Electronic Disease Early Warning System in Yemen.
  - Ghana: Integrated Disease Surveillance and Response system.
  - Kenya: Health Information System (Gray-Lobe and others 2022).
  - Rwanda: Health Management Information System (Mamuye and others 2022).
- Korea case study:
  - Single-payer mandatory health insurance registers all citizens upon birth; the health insurance number links with the national identity system and functions as a key identifier (Jung 2021).
  - A “DNA” (Data, Network, and AI technology) strategy created a special taskforce for digital health (2017); legal amendments during the pandemic allowed collection of data from banks, telecom firms, and surveillance cameras for contact tracing.
  - New data protection laws make pseudonymized data available for scientific research without consent.
  - In 2021 the government launched the My HealthWay app as a mobile-based public personal health record service (Lee 2022); My HealthWay integrates medication and vaccination data, can be linked to Samsung Health and Apple HealthKit, and is interoperable with EHRs in hospitals offering core primary health care functions.

### Expanding access through telemedicine
- Rationale:
  - Telemedicine helps address scarcity and uneven distribution of quality health care services, especially in rural and remote areas.
- Brazil:
  - The 1988 constitution established health as a universal right and created the Unified Health System (SUS).
  - Life expectancy rose from about 65 to 75 years in 2019 (UNDESA 2022).
  - Telemedicine legislation emerged in 2000 and was implemented in three phases; the ministry of health developed e-SUS software to integrate systems within SUS.
  - Rapid growth in adoption is evidenced by an increasing number of primary care units using digital records and more laptops and tablets used by health professionals (Brazilian Network Information Center and others 2021).
- China / Ping An Good Doctor:
  - Ping An Good Doctor allowed virtual patient–doctor consultations; by 2019 it had 315 million total registered users.
  - The company used big data cloud services to provide knowledge support to nearly 50,000 clinics and 100,000 pharmacies and thousands of other health providers.
  - Using data from more than 530 million online consultations, Ping An created an AI doctor; Ping An estimated a five- to tenfold rise in platform capacity thanks to the AI system (Chan Kim and others 2021).
  - In 2019 the Chinese State Council included internet health care in public health insurance reimbursement plans.

### Digital health in sub-Saharan Africa: infrastructure and constraints
- Opportunities:
  - Digitalization interventions (telemedicine, mHealth, eHealth) can help mitigate shortages of health care professionals and infrastructure and improve service coverage and quality for underserved populations.
  - Biometric identification systems are increasingly being invested in to enable data-heavy interventions and facilitate coordination across health, social protection, and education systems (Parekh 2020).
  - Integrated health information systems can increase data collection for decision making (Holly and others 2022).
  - Example innovation: The African Drone and Data Academy in Malawi educates students on drones and data; drones transport blood between clinics (Holst and others 2020).
- Barriers identified via interviews with digital health experts from 10 countries:
  - Weak leadership and coordination.
  - Underinvestment in basic infrastructure.
  - Weak information systems to support data sharing and interoperability.
  - Insufficient stakeholder engagement (Holly and others 2022).
- Importance of documentation:
  - Successful digital health interventions and their challenges should be well documented to support sustainable funding and scaling.

### Digital platforms for patent licensing and pooled procurement
- Medicines Patent Pool (MPP):
  - Established in 2010 in Geneva to improve patented drug access in developing countries by building a transparent drug patent database and sharing licenses online.
  - A systematic study of the HIV drug supply in 103 developing countries found the MPP increased generic drug supply by 7 percentage points (Wang 2022).
  - From 2010 to 2017, the total operating cost of the MPP ($33 million) was much smaller than the estimated consumer and producer surplus: $0.7 billion and up to $181 million, respectively (Wang 2023).
  - The MPP is a key partner of the COVID-19 Technology Access Pool and helps construct technology transfer hubs.
- Global Fund pooled procurement:
  - The Global Fund Price and Quality Reporting database (wambo.org) provides buyers access to procurement channels, including the Global Fund’s Pooled Procurement Mechanism (PPM).
  - The PPM allows countries to pool drug orders into larger volumes for better discounts and enables buyers to track order status, enter data directly, and enhance reporting and monitoring.
  - Research found the PPM reduced delivery delays but increased procurement lead times needed for advanced planning (Wang and Zahur 2022).
- Note: It can be challenging to disentangle the effects of digitalization from the impacts of pooling because digital platforms are integral to the institutional design.

### Global digital health repositories and knowledge sharing
- WHO Digital Health Atlas (DHA):
  - A global technology registry platform to coordinate digital health efforts and strengthen the value and impact of digital health investments.
  - Provides a standardized format for stakeholders to access, report, and share information on digital health projects.
  - As of February 2023, the DHA had 944 projects registered, reaching about 4.74 million health workers and more than 1.56 million facilities.
- UNICEF Digital Health Centre of Excellence (DHCE):
  - Established in 2021 to support UNICEF’s Digital Health & Information System unit and WHO’s Digital Health and Innovation Department.
  - Provides technical assistance on development and scale-up of digital health solutions, including drug purchases and delivery, service delivery and management, epidemiological surveillance, and workforce training.
  - By January 2023, the DHCE had provided 38 technical assistance engagements of 11 types to 58 countries.
- World Bank and 3ie evidence gap map:
  - Categorizes studies by intervention types and associated health, economic, and behavior outcomes (World Bank and 3ie 2019).
  - Finds ample literature on interventions directed at health care clients and providers, but a considerable evidence gap on interventions related to health system management and data services.

*Source: IMF Note NOTE/2023/004*

### Conclusion

### Conclusion

### Key findings on digitalization and health interventions
- The increasing public and private investment in digitalization has resulted in broader use of digital health interventions to improve data quality, public service delivery, and market efficiency.
- Literature review and country case studies (Table 1) revealed promising impacts of digital health interventions, but questions on how to maximize their impact while investing in foundational health and connectivity infrastructure, as well as managing privacy concerns, remain.
- More comprehensive data and research are needed to untangle the effects from digitalization itself from the expanded access to existing healthcare services, and to understand the cost-effectiveness of different interventions.

### International coordination and initiatives
- International efforts to develop, coordinate, and use digital health tools have grown.
- Institutions like the MPP and the PPM have used digital tools to improve the licensing, purchasing, and delivery of drugs to developing countries.
- Major health international organizations like the WHO and the United Nations have been refining their open access global repositories to enhance information sharing, standardization, coordination, education, and technical support.

### Implications for IMF engagement and macrocritical health issues
- The high-level policy insights on digitalization and health care discussed in this note could support IMF engagement with country authorities on macrocritical health-related issues.
- IMF country teams have become increasingly engaged on health spending issues in surveillance and program work—and more so during the COVID-19 pandemic (IMF 2019, 2023).
- The note explains how digital interventions might help address macrocritical health care issues related to:
  - Spending adequacy (for example, increasing access to health services for underserved populations with remote service delivery).
  - Efficiency (for example, using digital health records to ensure timely access to medical data).
  - Sustainability (for example, drawing evidence-based insights from digital interventions to ensure sustainable financing and service continuity).

### Table 1 — Summary of Country Cases (selected challenges and digital solutions)
- Challenge: Access to remote and rural areas
  - Country cases: Brazil and sub-Saharan Africa
  - Digital solution: Telemedicine, access to laptops and tablets, data, and drones
- Challenge: Transferability of records
  - Country cases: Estonia
  - Digital solution: Centralized standard e-patient portal
- Challenge: Interconnectivity, geolocation, and tracing
  - Country cases: Korea
  - Digital solution: Integrated centralized insurance system with other data, and mobile-based health records
- Challenge: Access to quality health care
  - Country cases: China
  - Digital solution: Umbrella health care provider and AI doctor

*Source: insea2023004 - Conclusion.*

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_Source: https://www.imf.org/-/media/files/publications/imf-notes/2023/english/insea2023004.pdf_