Abstract
The digitalization of healthcare- considered as the collective outcome of individual digitization attempts- is an ongoing global trend, which has accelerated during the COVID-19 pandemic. It occurs at a different rate and follows different implementation pathways across the world. However, there is still little published information relating to this process in Low-and Middle-Income Countries (LMICs), a knowledge gap which this good addresses head on. In this first chapter we present an overview of the main themes of the current book, the rationale behind the choice of terminologies and also the aims of this book. The latter are to highlight the many yet disconnected success stories from LMICs, to identify challenges and opportunities, and to maintain the spotlight on the dynamic nature of the healthcare digitalization process.
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1 What Is Digital Health
The term digital health has many definitions in the current scientific literature, like many other technologically-driven terms, e.g., Artificial Intelligence (AI). For the purposes of this book, the overall definition remains quite general, i.e., a collection of activities that includes digital care programs, technologies within healthcare and society, aimed at enhancing the efficiency of healthcare delivery and in making medicine more personalised and precise (Fadahunsi et al. 2021). The necessity for the adoption of such a broad definition, stems from the very topic of this book. Low- and middle-income countries (LMICs) do not constitute a uniform entity, even though they often get grouped together for the purposes of simplification. Instead, LMICs are a collection of individual cases that present many similarities and overlaps in healthcare, due to their underlying commonalities, e.g., resource-restricted settings, population pressures, healthcare burden, etc. As such, the implementation and potential adoption of digital health will be highly context-driven, thus, the definition of digital health would need to remain broad so as to ensure inclusivity. Indeed, this book hosts chapters contributed by over 100 authors from over 25 countries, covering as many aspects and perspectives as that was possible to achieve within the publication confines imposed by the nature of a book publication.
2 Why Is It a Good Time to Talk About Healthcare Digitalization in LMICs—Coalescence of Forces
A number of distinct factors justify the creation of the current book at this point in time. The information explosion in healthcare is well-known (Wilson 2001; Beath et al. 2012), and is the result of a significant increase in computing power, coupled by a significant reduction in data storage costs, facilitating the production and storage of increasingly larger volumes of data (Shastri and Deshpande 2020). At the same time, the increasing penetration of hand-held and internet enabled devices had led to an explosion in data generation and data consumption within healthcare (Feroz et al. 2020; Wood et al. 2019). In turn, this increasing need on both sides of data, i.e., significant increase in production and consumption of healthcare data, lays the ground for further innovative approaches, utilizing the new technologies needed to cope with the digital pressures within healthcare. New methods of inquiry are emerging in thinking about innovations in the wider healthcare field, and that is inevitably also reflected in the approaches of understanding and interpreting those findings for the scientific literature (Kozlakidis and Catchpoole 2021a). This is particularly true within LMICs, where driven by the necessity of severe funding limitations for example, digital healthcare implementations may be very innovative.
Thus, as alluded above, one main factor is the technological advance (from ‘-omics‘analytical technologies to digital surveillance programs used for public health), able to accommodate more functions than ever before, and as such generating more data than ever before. The second main factor is the market itself: there exists a more mature environment for digital health applications as part of routine practice. Indeed, the COVID-19 pandemic has functioned as an accelerator in terms of entrenching digital technologies within routine services (Kozlakidis and Catchpoole 2021b). For example, digital technologies have been used for remote post-operative monitoring more intensely than ever before (Beauharnais et al. 2022; Mousa et al. 2019), as well as an innovative platform for bringing healthcare professionals and patient groups together, e.g. breast cancer patients (Abusanad 2021). While it is anticipated that some of this activity may revert to pre-pandemic protocols, this is not going to be universally true, and as such a considerable portion of digital healthcare capacities will remain integrated within the overall healthcare systems (Jazieh and Kozlakidis 2020), strengthening the existing digital healthcare market, and its relative position as proportion of the annual healthcare budget. Thirdly, there is an accelerated penetration of mobile phones that has now been coupled with increased penetration of internet-enabled services (Kelly et al. 2020). Whereas mobile phone penetration in south-east Asia has been over 90% in most major countries for over a decade, the necessary internet-enabled infrastructure, i.e., ensuring sufficient connectivity and bandwidth, such as needed to operate healthcare applications, has only been available for only a few years in most locations, if at all (Hoe 2022). Finally, the COVID-19 pandemic has provided the required evidence that digital healthcare implementations can be financially viable, e.g., in the servicing and monitoring of repeat prescriptions (Macariola et al. 2021). However, such cases are still the exception within LMICs, and a wider adoption would require appropriate policy support (Bloom 2019).
3 Focusing on LMICs vs Resource Restricted Settings
Healthcare systems in many LMICs are complex and tend to operate under immense pressures in terms of healthcare delivery. However, it is also appropriate to recognise that many LMIC healthcare systems have undoubtedly improved over the last few decades (Dinh et al. 2020). For example, the areas of maternal health and preventative medicine have benefited from a sustained drive to implement universal standards of care (Siseho et al. 2022). It is also appropriate to recognise that there exist pronounced healthcare access inequalities within high-income settings, and that certain regions of high-income countries (HICs) may indeed not be all that different for LMICs in terms of healthcare access (Doty et al. 2021). In the latter case it might be more appropriate to speak of resource-restricted settings, irrespective of the reported national average income, as a more representative picture. The opinion of the editors of this book is that indeed a resource-restricted setting perspective will be more appropriate in the longer-term, and as more data becomes available. Such a shift in terminology and research frameworks would become both inevitable and complementary to the current LMICs/HICs view. However, at present the LMICs focus of this book serves a dual purpose: (i) continuity and easier comparability with the published scientific literature, as well as (ii) the view of digital healthcare innovations and implementation within the framework of universal healthcare coverage, as has been supported and introduced in many LMIC settings in the last two decades. From a digital healthcare perspective, it remains paramount to still understand the systemic challenges and opportunities, prior to fragmenting investigations further within regional settings that can be stratified according to local income availability.
4 The Nature and Aim of this Book
Taking the above into account, the aim of the book is to provide a representative picture of healthcare digitalization in LMICs. Specifically, how digital healthcare applications have been implemented in particular countries and healthcare fields, e.g., paediatrics, dentistry, medical genetics, etc. In doing so, the book is highlighting specific examples, the plurality of context-driven solutions, and the many opportunities that still exist regarding digitalization of healthcare in LMICs. To this end, the example of the Kingdom of Saudi Arabia is utilised as the benchmark of high attainment in terms of integration of digital health, within a purpose-driven policy framework. The examples from Poland, Cyprus and China talk about the transition economies that have successfully integrated many digital health applications within routine operations, yet a fully integrated digital healthcare ecosystem has not been fully attained (but remains firmly within their grasp in the immediate future). The chapters with LMICs-specific examples, are supported by extensive work on the necessary preconditions for digital healthcare success, such as infrastructure, investment, systems design, social acceptance, etc. Over 80 authors from 15 different countries, most of which are LMICs) have contributed to the chapters presented in this book. It is a deeply collective work that provides a holistic and representative view of the current nature and status of individual digitization attempts of healthcare in LMICs, as well as the collective view of digitalization. From the editorial perspective, we anticipate that his book will spur many forward scientific discussions on the subject, and will form the basis of further such investigations on what is perhaps one of the most critical aspects of the future, global healthcare systems.
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Acknowledgments
The editors would like to thank the many reviewers who provided constructive comments to the chapters, the many authors who provided their insights into this subject, as well as the publishing house staff, namely Mahalakshmi SathishBabu Nithya Sechin, Emily Wong and Grant Weston. Particular thanks go to Ms. Tracy Wootton for her administrative support to the editors and helpful insights throughout the collation of this book.
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Kozlakidis, Z., Sargsyan, K. (2024). Digitalization of Healthcare in Low-and Middle-Income Countries (LMICs): An Overview. In: Kozlakidis, Z., Muradyan, A., Sargsyan, K. (eds) Digitalization of Medicine in Low- and Middle-Income Countries. Sustainable Development Goals Series. Springer, Cham. https://doi.org/10.1007/978-3-031-62332-5_1
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