Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis

"...just a few examples of successful digital health interventions carried out in Pakistan, despite limited resources available due to the financial constraints of the country..."

Digital health is well positioned to revolutionise health care in low and middle-income countries (LMICs) due, in part, to increasing mobile phone access and internet connectivity. This paper examines digital health projects carried out in Pakistan from 2015-2020 and evaluates them through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to clarify facilitators and barriers to progress in digital health in Pakistan.

A search strategy similar to that of a systematic review was used to identify interventions, projects, studies, or smartphone applications (apps) that had been carried out in the field of digital health in Pakistan. The project team then made efforts to contact the stakeholders of the projects identified in the literature search, to survey them about their work, and to invite them to take part in co-design workshops in various cities in Pakistan. Fifty-one stakeholders, each representing an individual study or intervention, were engaged. The set of projects selected is representative of all the provinces in Pakistan.

Of the projects studied, 46% (23/51) used technology for conducting research, 30% (15/51) used technology for implementation, and 12% (6/51) used technology for app development. Smartphones and devices were used in 55% (28/51) of the interventions, and artificial intelligence (AI) or machine learning (ML) was used in 31% (16/51) of projects. Fifty-nine percent (30/51) of projects included plans for scaling up, and 74% (38/51) of interventions were being evaluated.

The health domains targeted were general health (23/51, 46%), immunisation (13/51, 26%), and diagnostics (5/51, 10%). For example, as many female doctors leave clinical practice due to household and childcare responsibilities, telemedicine initiatives such as eDoctor (SE Software Technologies) and Sehat Kahani (Grocode.io) enable them to conduct their medical practices remotely via online patient consultation through a telehealth platform. Another intervention, a mobile app called Teeku (Aga Khan University), is designed to help vaccinators record immunisation data for better monitoring and improved coverage of expanded programme on immunisation (EPI) vaccines. Outbreak investigation and surveillance is another relevant public health domain that can be improved with digital health interventions. For example, in 2 recent epidemics of the extensively drug-resistant typhoid and human immunodeficiency virus (HIV) in the province of Sindh, geospatial mapping helped identify the root causes of the outbreaks and isolate cases and their spreads.

The barriers faced by developers during the implementation phase included the populations' inability to use the technology or mobile phones in 21% (11/51) of projects (less than one-third of the population owns a smartphone), costs in 16% (8/51) of projects, and privacy concerns in 12% (6/51) of projects. Several of the weaknesses and threats associated with human resource capacity are linked to the lack of any formal programme in digital health in Pakistan. Other barriers to implementing the technology identified during the co-design workshops include: (i) patentability; (ii) little deployment of mHealth apps and new digital tools in current clinical practices; (iii) lack of evidence on the validations of digital health devices and smartphone apps; (iv) unavailability of regulatory frameworks; and (v) communication challenges due to the complexity of digital health projects and involvement of experts from diverse domains in these projects. Specifically, there were weaknesses when it comes to exchanging ideas and initiatives, primarily between physicians, technology experts, and researchers, and a low trend of sharing data widely, as reflected in the low percentage of studies published in the public domain.

The study reveals the need for advanced collaborative pathways to improve user wellbeing, where the roles of investors, their responsibility, rights, and transparency are clearly described. There is currently a limited national effort dedicated to addressing the ethical concerns that arise in digital health projects, such as data privacy, retention, and determining the situations when consent is not required. Thus, there is a need to establish national-level ethical frameworks, to standardise consent norms, and to identify the regulatory approvals needed before a project can be implemented and launched, especially when something is scaled at a larger level.

This study and SWOT analysis were conducted just before the global COVID-19 pandemic. Since then, the role of and demand for digital health has increased significantly, and in some scenarios, it is the only viable solution for moving forward while following a social distancing strategy. The researchers note that, in Pakistan, the use of digital health technologies in handling the COVID-19 pandemic has surged, especially in the public sector. Examples of interventions being implemented include: (i) real-time registries and dashboards to visualise and download positive cases and relevant data, (ii) a COVID-19-specific telehealth portal where patients can consult a doctor online, and (iii) an SMS (short messaging service) text-messaging–based emergency cash transfer programme providing financial support to citizens identified by the government's poverty criteria during the enforced COVID-19 lockdown.

In conclusion: "Digital health-based interventions are, slowly but steadily, being ushered into the existing health system of Pakistan. There are still significant hurdles, barriers, and roadblocks in the form of limited internet facilities, phone ownership, network coverage, unavailability of regulatory frameworks, data protection and security regulation, accessibility, affordability, and paper-based health records, limiting the types of technologies that can be utilized for effective interventions. However, despite all the challenges, digital health is steadily expanding through the efforts of multiple stakeholders in both the public and private sectors."