When I joined an INGO in 2019 for the Rohingya crisis, I was exposed to a wide range of health needs that seemed to exceed the capacity on the ground, while ironically coming into one of the places where humanitarian assistance was more robust than any other humanitarian context I’d seen or studied. Since the start of the mission, I noticed certain hesitations surrounding the health strategy in the operation I was engaged in, mostly due to the low utilisation rate of services. However, with time, what became clear was that the affected population lacked awareness of the services, as they were located beyond the refugee camps, and this required time to address. This situation was reflected in their health information system (DHIS2) in the coming weeks, when we gradually amassed convincing arguments to continue with the activities. After six months of consistently analysing the data, it became evident that opting for a progressive increase in hospital capacity was the correct course of action. I think this is a good example of how using data effectively can support decision-making and thus make a significant impact on both the individual lives of the affected population and the adequate delivery of healthcare services.

My experience in the midst of the Rohingya crisis is a very small example of the need for effective digital solutions in order to strengthen data-based decision. In recent years, especially during and after the COVID-19 pandemic, there has been a notable surge in the adoption and advancement of those. This surge has significantly enhanced healthcare coverage in numerous countries, including countries facing humanitarian crises. Throughout this period, many countries, along with national and international actors, have undergone digital transformations to improve and optimise their health services and the healthcare quality.

In this article, I will explore, through some examples, the significance of these changes and how they contribute to accelerating health coverage in humanitarian setting. But before, let's take a moment to explore some of the factors contributing to this progress, along with the challenges arising from the ongoing transition

Infrastructures & rules, the seeds for growing digital ecosystems

Increasing technological infrastructure

Regarding technological infrastructure, two major elements seem to be key for increasing the health coverage in the upcoming years: the growing momentum around 5G technology and the accessibility of smartphones.

In many areas, and especially in low-and-middle income countries, the lack of robust technological infrastructures hinders the resort to digital resources in the different levels of services: population, health providers, health authorities, coordination groups and other complementary data services, such as geospatial information or data governance bodies. Presently, when existing, 2G and 3G technology are the dominant network infrastructure in humanitarian settings, presenting a contrast with the status towards 5G in western countries.

Considering the scarcity of the proper infrastructures and the unpredictable context in some areas, suppliers of these technological services will explore cautiously cost-effective approaches to facilitate this investment. This is evident in countries such as South Sudan, Somalia, or Central African Republic, where the internet penetration rate is among the lowest according to available data, with approximately 90% of their populations either not having access to the internet or facing significant challenges in using it.

When turning our attention to the second key element, projections suggest a significant upswing in smartphone adoption by 2030, particularly due to an increase in affordability. The anticipated surge is, for example, from 51% to 92% in the Economic Community of West African States (ECOWAS), an area considered by the UN Office for the Coordination of Humanitarian Affairs (OCHA) as the epicentre of a fast-growing crisis with unprecedented armed violence and insecurity.

The role of data security and regulations

The second driver for growing digital ecosystems consists of data security and regulations. The sensitive nature of health data determines the need for legislation and policies, which plays a role in shaping the landscape of digital health and framing the digital health ecosystem. This aims to create trust among civil society and actors, by ensuring confidentiality of their health data or the data they are collecting. National safeguarding rules, such as data sharing regulations, or interoperability standards, allow data to be exchanged responsibly and securely in those humanitarian settings.

However, action is needed not only at the national level; extending regulations to supranational coordination and NGOs in humanitarian settings was also necessary. Notably, in 2021, the Inter-Agency Standing Committee (IASC) took a significant step by introducing the inaugural operational guidance on data responsibility in humanitarian actions. IASC defined this as "the safe, ethical and effective management of personal and non-personal data for operational response, in accordance with data protection regulation.”

This guideline aims to contribute to the secure handling of personal and non-personal data by recommending actions at three levels of implementation: system-wide, cluster-level, and organisation level. What is particularly relevant about it is that it considers the challenges and idiosyncrasies of humanitarian settings and how it should be contextualised accordingly, covering the gap that previously existed in guidelines for these specific contexts.

Personally, I hope to see more reference to organisational levels coming from this implementation experience, since this is, from my point of view, where challenges may be more pronounced due to resource constraints in contextualising the guidelines and their closer proximity to health users.

Looking ahead, we should expect supplementary examples and feedback from the implementation on the ground, to complement the existing guideline. Personally, I hope to see more reference to organisational levels coming from this implementation experience, since this is, from my point of view, where challenges may be more pronounced due to resource constraints in contextualising the guidelines and their closer proximity to health users.

Embrace digital health, stay patient, and avoid predictable obstacles!

I must say that, in my experience, I faced several challenges when implementing digital solutions in humanitarian settings, and the lack of progress has been a source of frustration. The challenges in the realm of digital health are multifaceted, more even so in volatile and unpredictable contexts, and we must anticipate obstacles such as predictable lack of training in device usage, lack of understanding of the purpose and benefits of collecting data, or digital interventions without a culturally-based approach. An illustrative example I can share takes me to Venezuela while providing support to the implementation of a health program for an INGO, where language was identified as a barrier to using the platform. To overcome this, we incorporated local translation to facilitate utilisation.

Reflecting on my varied experiences with digital interventions, I believe there is a need for a more substantial investment in anticipating and addressing local challenges in a comprehensive manner, to effectively shape the digital transition.

Furthermore, the implementation of digital health solutions not tailored to local behaviours and capacities, combined with the vulnerability of specific groups such as children, the elderly, or women, can inadvertently worsen existing inequities. For instance, implementing digital payment in settings where women have restricted access to mobile phones, can actually exacerbate disparities. Reflecting on my varied experiences with digital interventions, I believe there is a need for a more substantial investment in anticipating and addressing local challenges in a comprehensive manner, to effectively shape the digital transition.

On the other hand, in certain contexts, I've noticed a prevailing trend for digitising everything without a clear roadmap or coordination. I have identified one cause and two consequences of this approach. Firstly, in some humanitarian settings, there seems to be a lack of strong leadership guiding the transition, resulting in disruptions. Regarding consequences, these are twofold: on one hand, there is fragmentation in digital interventions, occasionally leading to duplications of existing efforts; on the other hand, the sustainability of these initiatives is questionable due to dependency on donors, turnover of key decision-makers, and uncertainties surrounding the cost-effectiveness of these initiatives.

Despite all of this, I must say that, having seen the potential of various initiatives, globally and locally, I'm optimistic about getting closer to universal health coverage with strong contributions from digital health solutions. On a global scale, I witnessed the launch of the Global Digital Health Monitoring initiative with great enthusiasm, an effort that engages countries in tracking progress on the implementation of digital health initiatives, through the assessment of different indicators, including in places experiencing humanitarian crises like Niger, Mali, or Yemen. While this is a great tool, the possibility of exploring the status of implementation in humanitarian crises across countries, or assessing sub-national levels of coverage, such as administrative areas (e.g. municipalities, bomas, among others), could greatly benefit the humanitarian sector.

Emerging technologies for improving access to Universal Health Coverage

OCHA identified nine emerging technologies. From my point of view, three of them have the greatest potential to boost Universal Health Coverage. The first is digital cash transfer. The shifting trend from in-kind assistance to cash-based assistance will position digital payments as an impactful tool in enhancing access to the full range of quality health services, without financial hardship, for affected populations in humanitarian settings. Together with the smartphone adoption upswing mentioned before, this transition will empower individuals, particularly beneficiaries, and also health workers, by facilitating easy, transparent, traceable, and cost-effective transactions. I observed this as one of the options used by UN Agencies for paying frontline workers in immunisation campaigns, which ultimately contributes to the effectiveness and success of the campaigns.

The second emerging technology mentioned in the OCHA publication that I would highlight, include mobile apps, chatbots, and social media. Particularly on social media, engaging communities in healthy behaviours has become crucial for the effectiveness of humanitarian responses. For example, the experience I mentioned during the Rohingya crisis illustrates how social media could have served to inform and alerting communities about available services. At the same time, social media is not limited to one-way communication; they also serve as channels for collecting information from diverse sources, fostering a better understanding of crises, and enabling proactive responses, even in the most remote and hard-to-reach areas, something that has not been fully explored, potentially due to the capacity to verify the information.

The last one is predictive analytical models, which enable transitioning from reactive interventions to a more anticipatory approach to health emergencies, which will significantly impact access to health services and enhance coverage. These models are already playing a crucial role in supporting decision-making processes and interventions, such as it is the case for the Malaria Eradication Program, or the Cholera Response Simulator Initiative.

In the ever-changing landscape of challenges and possibilities in the digital health environment and humanitarian settings, one thing is clear: there is no way back on this transformative journey. Digital innovation becomes the beacon of hope, breaking down barriers, and leading us to a new era of healthcare accessibility.

References

GSM Association. (2023). The Mobile Economy: Sub-Saharan Africa 2023.

GSM Association. (2023). The Mobile Economy: Middle East & North Africa 2023.

Digital Health Monitor. (2023). Retrieved from https://monitor.digitalhealthmonitor.org/ map

Data Protection Africa. (n.d.). Retrieved from https://dataprotection.africa/

Arias, A., Wright, A., & Waszak, J. (Year, if available). Digital Health Systems in Africa: A convergence of opportunities. EMEA Thought Leadership, IQVIA.

World Health Organization. (2019). Primary Health Care on the Road to Universal Health Coverage: 2019 Monitoring Report.

Data Responsibility Working Group. (2023). Operational Guidance: Data Responsibility in Humanitarian Action. Endorsed by IASC Operational Policy and Advocacy Group (OPAG). April 2023.

United Nations Office for the Coordination for Humanitarian Affairs (OCHA), Policy Branch. (2021). From Digital Promise to Frontline Practice: New and Emerging Technologies in Humanitarian Action. Hansjoerg Strohmeyer, Chief of Branch; Quynh Tran, Project Lead; Murad Jeridi, Contributor; Maria Louise Aguiling, Research Assistant.

Rocca, R. (2021). Complex Systems Modelling for Humanitarian Action: Methods and Opportunities. Data Fellow (Predictive Analytics), OCHA Centre for Humanitarian Data. November 2021.

World Health Organisation. (2023). Classification of digital interventions, services and applications in health: a shared language to describe the uses of digital technology for health, second edition. Geneva: World Health Organisation. Licence: CC BY-NCSA 3.0 IGO