COVID-19: A Catalyst for Digital Health at MSF?
MSF, and others in the healthcare space, are facing increasing proximity challenges - particularly in low resource and humanitarian settings. It was estimated by the WHO and World Bank (World Health Organization, 2017) that approximately half of the world’s population lacks access to essential healthcare services. This was before COVID-19.
Now we are facing an even more pointed strain on skilled human resources for health (HRH), a mounting prevalence of complex multi-morbidities in the contexts we work requiring more individualised care in addition to other access constraints associated with the current pandemic. As MSF is continually committed to alleviate suffering and improve health outcomes, both in response to COVID-19 as well as within our regular and emergency interventions, it is becoming clear that digital health may help to address some of these issues if implemented within an appropriate health system.
It is clear that health seeking behaviours, regulation, reimbursement and health system buy-in is at a tipping point catalysed by COVID-19, signalling potential for more sustained digital health adoption in the long-term. Digital health has been seen as a secondary option, and a potentially risky investment, in the global health and humanitarian space to date with outstanding questions and barriers around clinical efficacy, data protection, and much more. This has led to relatively small-scale and fragmented digital health implementations in global health scenarios. However, we are now being pushed to decrypt these essential questions and navigate associated challenges as the demand for remote health care and support balloons, particularly for high-risk patient populations (e.g. TB/HIV).
So, what are some of the key insights we have gained so far? How is digital health manifesting in MSF at present? What challenges are MSF, and others in the global health and humanitarian health sector, facing as we wade deeper into the largely uncharted waters of digital health ecosystem creation? And what is the long-term opportunity and aspiration? Read on for our round-up of just this.
Our Key Digital Health Learnings so Far
When we reflect on some of the digital health efforts in MSF to date there are a handful of central learnings that stand out and can be broadly leveraged to improve any digital health project:
Collaborate: While healthcare is currently trending towards hyperspecialization, digital health is a very different beast. Digital health will not be ‘solved’ by one area of expertise. It is not strictly clinical nor strictly IT. Digital health efforts require a blend of expertise including medicine, health promotion, health and social research, IT, legal, data protection. Multidisciplinary teams should be engaged in digital health efforts for maximum impact.
Think in Systems: In its earliest days, digital health was hailed as a remarkable way to break down inefficient silos in healthcare. However, as time went by it became clear that structural issues and varied buy-in meant small pilots and rapid deployments started to spring up with no collective base. Digital health should be approached as an ecosystem issue that requires appropriate structures. The humanitarian and global health sector is complex. So is digital health - it will require feedback loops, training, adjusted resourcing etc. Denial of digital health complexity is simply deferring and amplifying issues for a later date. We need to embrace complex systems thinking with open arms and avoid rigid linear thinking.
Scale Understanding: Creating a shared glossary of terms to discuss digital health cannot be overlooked in its importance - what do you mean by telehealth/telemedicine/remote patient monitoring/ehealth/mhealth etc.? This should be documented, disseminated, validated and revisited frequently. Additionally creating resources and platforms for sharing of information between different MSF operational centres and field teams on what has worked or failed for them in the digital health space helps to avoid duplication of efforts.
Be Patient First and Field First: If a digital health solution is highly disruptive to a field/clinical workflow you will rapidly reduce the likelihood of success. We cannot expect already stretched filed teams to take on a disruptive tool. Likewise, for patient-facing interventions, we must consult with the target populations to understand the problem we are trying to solve and their experience of it. Consulting with patients and field teams should be factored in throughout the digital health development and implementation process. This is non-negotiable. It is also important to engage those outside of the digital health ‘inner circle’. Speak to skeptics early, listen to their concerns and mitigate against these roadblocks later on.
Digital Health in MSF
While the digital health space has been booming in high-income contexts since the early 2000s the global health and humanitarian sectors have not had the same luxury to experiment as vastly. However, this is not to say that digital health innovation has not been adopted and explored - merely taking a different path at a different pace. At MSF 2020 has given new energy and interest to digital health efforts across the movement.
Telehealth has been a central aspect of MSF digital health activity. Telemedicine (defined as clinical interactions via video calls or other phone-based interactions), for example, has been up and running in MSF for a decade. The MSF Telemedicine system, first launched in 2010 and focused on store-and-forward exchanges between MSF clinicians looking for a second opinion on complex cases from the field provides A VALUABLE RESOURCE FOR FIELD TEAMS DEALING WITH SEVERELY RESOURCE LIMITED SETTINGS AND RESTRICTED REFERRAL ABILITY. Since its initial launch Telehealth demand has increased substantially in MSF leading to a demand for an expansion beyond provider-provider interactions and towards patient-provider communication. This new wave of telehealth in MSF is both clinical and non-clinical. The clinical interactions encompass diagnosis, treatment and prescription via digital means e.g. mental health consultations for migrant populations. Non-clinical telehealth interventions may include digital health promotion focused interactions such as providing COVID-19 guidance on hand-washing and what symptoms to look out for. With the learnings from the teams who have already implemented telehealth in MSF we have just completed the MSF Telehealth Toolkit, intended to support the pre-launch decision making, implementation and evaluation of telehealth interventions. MSF staff can view the full toolkit here.
Some other digital health endeavors at MSF include digital patient support tools for patients with long term or chronic conditions such as tuberculosis. One example of this is the SIU DIGITALLY SUPPORTED TB CASE which is seeking to validate a solution supporting medication adherence, health education and mental health counselling of patients. Like many digital health solutions that are in progress or planned in the MSF movement this will be delivered in a hybrid model, offering patients both in-person consultations where needed and appropriate and the digital support tool between visits.
Digital Health Promotion (DHP) has been one of the most active and impactful elements of the MSF digital health activities to date. This has included a SMARTPHONE GAME FOR HEALTH PROMOTION particularly tailored to Ebola and LATER ADAPTED TO COVID-19. The DHP team recently released a TOOLKIT FOR MSF STAFF looking to set up and run campaigns which also tackles some of the challenges listed below, such as the ethics of using Facebook or WhatsApp.
Digital Health Challenges in Global Health and Humanitarian Health
We still have a long way to go but the challenges are becoming clearer and our ability to tackle them more refined with each day. Some of the greatest barriers we are focused on at the moment include:
Data Protection: Navigating data protection is a daunting task for teams looking to launch a new digital health solution, particularly those that may involve collection of identifiable patient data. While WhatsApp seems to be one of the most accessible tools and seems appealing for two way communication, how do we navigate data protection and when is it ethically out of the question? We are working closely with a range of experts internally including the MSF Data Protection group to find a way to support the safe and effective launch of digital health solutions and answer some of these burning questions.
Lack of Connectivity: According to a recent report from the Broadband Commission it is estimated that $100 billion will be needed to achieve universal access to broadband connectivity in Africa alone.
Scaling Evidence-Based Solutions Across Cultural Contexts: While there is growing evidence indicating the great potential and early impact of digital health services, there is a clear severe deficiency of robust peer-reviewed evidence validating these approaches and sharing learnings from low-resource, humanitarian and global health settings. This is a compelling insight for MSF to ensure that as we expand our digital health ecosystem we disseminate our insights and findings relevant to grossly underrepresented contexts. For MSF scaling across languages and cultures doesn’t necessarily mean crossing international borders - for example in the refugee camps of Greece the population we are providing health services to may speak upwards of four different languages.
What is Next for Digitally Supported Global Health?
There is significant momentum behind the digital health efforts at MSF. Now we must continue to channel this towards effectively addressing the challenges above and building out a coherent digital health ecosystem. There is still much to do, but we firmly believe we are on the right track to making this standard of care where it is most needed and ultimately improving the health outcomes and health support systems of patients and communities globally.
Are you a part of the MSF Movement and interested in learning more about Telehealth? Check out the preliminary MSF Telehealth Toolkit HERE.
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