Potential of Digital Health Solutions in Facing Shifting Disease Burden and Double Burden in Low- and Middle-Income Countries

Abstract

The changes in global health have fueled the concept of disease burden, and the process of how a shifting disease burden leads to a double burden has been observed in low-income countries (LIC) and lower-middle-income countries (LMIC) for the last few decades, replicating a trend experienced by high-income countries (HIC) in the previous century. Adding to the burden of communicable, maternal, neonatal, and nutritional diseases, non-communicable diseases (NCD) are becoming more prevalent due to socio-economic development that changes lifestyles in an aging population resulting in significant increases in life expectancy. The shifting disease burden drives healthcare systems to change accordingly to provide an adequate response. In the meantime, unsolved problems of inequality, shortage of medical personnel, and high prevalence of infectious diseases remain significant, putting massive pressure on the limited resources of healthcare systems in LICs and LMICs.

This is where digital health brings its promising potential, firstly to better understand the disease burden itself for an accurate conception of the health risks for the population, secondly to develop new solutions that will improve the efficiency of the current healthcare ecosystem, alleviating constraints and overcoming the lack of resources, and finally to provide better health outcomes for individuals as a customer-centric solution. Applications like health information technology (health IT) with electronic health records (EHR) offer an inclusive perspective on a patient’s total health and access to all healthcare providers, insurers, and other healthcare stakeholders. Mobile applications and wearables empower and engage patients in self-care management while real-time monitoring, collection, and exchange of their health status provide a continuous image of their health. Such solutions used together can build a strong history of a patient’s health status, and the data can then be used in conjunction with other data, such as genomics, etc., for early detection of many kinds of diseases, providing space and time for rapid treatment through personalized and precise medicine that works better for each individual, going towards more preventive care and wellbeing, which is particularly effective in managing NCDs. On the other hand, telehealth, using digital information and communication technologies, has already proven its usefulness in dealing with communicable diseases, as recently seen during the COVID-19 pandemic, while improving healthcare access and cost for rural, remote, and marginalized communities. The applications vary and are constantly updated as new technologies emerge, with numerous interrelated factors driving the changes.

This chapter studies LMICs in particular as they are the most strained and impacted by the double burden and provide us with insights into the challenges and the opportunities that emerge with digital health solutions as contenders. Amongst LMICs, Vietnam is an interesting case due to its rapid socio-economic growth that brings homegrown solutions to the local and foreign markets, while facing important health and inequality issues. As such, in dealing with the double burden and particularly for LMICs, digital health promises to be the answer for gaining equitable and universal access to high-quality healthcare that is both cost-effective and affordable. In highlighting this, indicative examples will be presented to illustrate the point.

1 Shifting Disease Burden in Low- and Middle-Income Countries

Disease burden refers to the human and economic costs resulting from poor health. Human costs refer to the gap between an ideal situation of living in old age with good health and the actual situation where health is impacted by disease, injury, disability, and premature death. The economic costs are the financial expenses related to healthcare and loss of productivity/labor incurred due to illness for individuals, households, healthcare systems, and society in general. Disease burden enables the evaluation and understanding of the relative importance of disease and disability for the entire population. A better understanding of which condition poses the greater threat to society allows policymakers and public health practitioners to allocate resources optimally for better health outcomes.

Besides maternal, neonatal, and nutritional diseases or injuries, diseases are often referred to as communicable diseases or non-communicable diseases (NCDs). NCDs, such as heart disease, stroke, cancer, diabetes, or chronic lung diseases, are the leading causes of death worldwide. On the other hand, communicable diseases, such as HIV/AIDS, tuberculosis (TB), malaria, viral hepatitis, sexually transmitted infections (STD), reemerging diseases and neglected tropical diseases (NTD), remain the leading causes of death in low-income countries (LIC).¹ Globally, NCDs accounted for 60.8% of all deaths in 2000 and rose to 73.6% in 2019, whereas communicable diseases accounted for 30.7% of all deaths in 2000 and decreased to 18.4% in 2019 (Fig. 1). However, in recent times, the COVID-19 pandemic had a strong impact on the burden of communicable diseases and due to its associated complications for people at high risk, impacted the burden of NCDs too.

Fig. 1

Leading 22 Level 2 causes of global DALYs (1990 and 2019), all ages for both sexes combined. Lines between time periods connect causes; solid lines show increases or stagnation in ranks, and dotted lines show decreases in ranks. TB tuberculosis, CKD chronic kidney disease, NTDs neglected tropical diseases, HIV/AIDS human immunodeficiency virus/acquired immunodeficiency syndrome, STI sexually transmitted infections excluding HIV. (Source: GBD Compare, IHME Viz Hub (healthdata.org) )

Taking cardiovascular disease as an example of the NCDs, even though its general decreasing trend may paint a positive picture, there remains a crucial disparity between developed and developing nations. As a result, health policymakers must create preventive programs and improve patient care, specifically in developing countries.²

Thus, with tight global budgets for health and research spending, a better resource allocation is necessary to improve health outcomes effectively. Furthermore, in any given country, evaluating disease burden at the local level is critical to provide the needed population health information for national and local governments to make targeted and efficient public health policies and programs.

To obtain precise insights into the roots of disease burdens, healthcare policymakers must consider both fatal and non-fatal outcomes of each disease and their risk factors. This requires utilizing data on causes of death, prevalence and incidence rates of various conditions, and risk factor prevalence and exposures within the population while incorporating statistical models to create a holistic picture of health trends without bias or inconsistency.

Between 1990 and 2019, the shift in disease burden was observed worldwide, with NCDs increasing in the ranking of disability-adjusted life years (DALYs) per 100,000 people globally. On the other hand, communicable, maternal, neonatal, and nutritional diseases are showing a downward trend, particularly thanks to improving health and living standards in LICs and LMICs. Meanwhile, NCDs are on increasing trends in terms of rankings, highlighting the shifting disease burden throughout time (Fig. 1).

The shift is significant in LICs, LMICs, and to some extent in upper middle-income countries (UMIC) as well, but it is mainly in LICs and LMICs that communicable diseases remain prevalent. However, thanks to international and national programs, numerous investments and improvements have brought a decline in mortality and the spread of diseases such as AIDS, TB, malaria, or NTDs. Between 2000 and 2019, this shift can mainly be seen in Africa, the Eastern Mediterranean, and South-East Asia, where many LICs and LMICs are located. Overall, UMICs and HICs (as seen in the Americas, Europe, and Western Pacific) are experiencing a minimal ratio of communicable, maternal, perinatal, and nutritional conditions (Fig. 2). Nevertheless, a global pandemic like COVID-19 brings unprecedented changes to all regions, requiring collaborative efforts in tackling its impact on the state of communicable diseases.

Fig. 2

Composition of causes of death by WHO region, World Bank income group, and global, 2000 and 2019. (Source: World Health Statistics 2022, Monitoring health for the SDGs, WHO)

Whereas NCDs were traditionally associated with HICs, more than 75% of all NCD-related deaths occur in LMICs, with about 80% of all cardiovascular disease-related deaths occurring in LMICs. In 2000, 171 million people were estimated to have diabetes, and 2/3rd of them were living in HICs, but by 2030, WHO predicts that developing countries will have about 284 million people with diabetes. Amongst the most affected countries will be China and India, which respectively had 20.8 million and 31.7 million cases of diabetes back in 2000.

NCDs increase due to interrelated trends, including the decreasing share of deaths from communicable and infectious diseases thanks to better nutrition, public health and medicine, longer life expectancy, and population ageing. This shift in disease burden is also known as the epidemiological transition; the leading causes of disease and death are shifting from infectious and acute diseases to chronic and degenerative diseases. NCDs share four major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, and unhealthy diets.³ All are becoming more common in LMICs due to economic growth and increased purchasing power, the changing lifestyle, particularly from urbanization (often unplanned) and its corresponding sedentary behavior, and changes in nutritional intake due to food market globalization that have brought unhealthy food consumption.⁴ Environmental degradation, climate change, growing inequality, and air quality are other important factors that increase the burden of NCDs.

The shifting in disease burden happens predictably in part; throughout history, diseases have existed, evolved, and spread, and scientific advances have helped to study and understand these patterns for better health. Even newly named or rare diseases have been intensively investigated. Additionally, the patterns of diseases in developing countries can be found to slowly replicate those experienced in the developed world over the last century. This allows health policymakers and healthcare providers to anticipate upcoming challenges and prepare accordingly, while creating opportunities for investment in other areas of healthcare, shifting the focus from communicable diseases to NCDs.

Nevertheless, this shift remains multi-directional and cannot always be predicted easily, with radical, even surprising changes. A globalized and integrated world creates globalized disease patterns; societies worldwide suffer from more or less the same afflictions. Regular outbreaks of new diseases, such as COVID-19, can disrupt the global healthcare system and require a new response. Many diseases are induced by climate change too, which is becoming more and more of an alarming issue worldwide. Multidrug-resistant bacteria are slowly becoming more prevalent, becoming one of the most significant issues that medicine faces without any one-for-all solution; well-known pathogens evolve with time, eventually outpacing scientific knowledge and technologies.

As such, this shifting disease burden is one of the most impactful factors shaping the future of medicine, along with the development and adoption of new technologies (Fig. 3)⁵; and they are influenced by a multitude of socio-environmental drivers: increasing life expectancy, decreasing fertility rates, rising customer expectations and demands, growing inequality, human migration, climate change, resource scarcity, and declining quality of food and lack of nutrients.

Fig. 3

The 2024 Alternative Futures for Healthcare, four scenarios based on two key drivers (“Changing burden of diseases” and “Development and adoption of new technology”). (Source: Translink Corporate Finance and Institute for Future Research)

1.1 Double Burden

The Southeast Asian region is now experiencing a rapid demographic transition, with the ratio of the aged population continuously becoming more critical, with the overall Asian region expected to have 456 million seniors aged 65 or older by 2025, representing 10% of its population.⁶

With a shifting disease burden, communicable diseases remain a significant cause of death. Thus, the double disease burden is very relevant in the region, resulting in complex socio-economic and healthcare challenges for the governments and local communities. Double disease burden occurs due to a substantial prevalence of both communicable and NCDs. This rapid shift of disease burden leaves the region even more unprepared and lacking in resources. Despite general progress in living standards and healthcare, communicable diseases have had periodic rises, mainly due to solid urbanization and often inefficient healthcare systems that cannot cope with the increasing demand. On the other hand, the general progress in living standards and healthcare has also increased life expectancy, which increases NCDs amongst the older population (in LMICs, populations aged thirty-five and older).⁷

This resulting double disease burden is a common characteristic of many developing countries and can lead to a vicious cycle that could impede economic growth due to loss of economic activity. Such changes reflect the socio-economic development of the countries and progress made in controlling and curbing infectious diseases. The pace at which the populations are aging worsens the burden of NCDs in LMICs, putting a critical strain on the entire health ecosystem. HICs had longer to adjust while their populations aged, but developing countries went through this shift in a much shorter period.

With the strong urbanization rate in LMICs, bringing them into the globalized world, there is an increase in NCDs, creating similarities in disease patterns to HICs. However, the weakness and inefficiency of the healthcare system in LMICs do not allow it to control communicable diseases fully, leaving them to co-exist with the increasing rate of NCDs, and a creating a double burden of disease. Furthermore, NTDs are still affecting the poorest populations the most, and amongst developing countries, it happens too often to populations that are living in geographically remote areas, ethnic minorities (EM), or marginalized groups, which exposes them to an intense vulnerability to an even greater range of diseases. In addition, other NCDs are also of public health importance such as renal, endocrinal, neurological, hematological, hepatic, gastroenterological, musculoskeletal, skin, and oral diseases; mental disorders; disabilities, including blindness and deafness; violence and injuries. NCDs and their risk factors are also linked to communicable diseases, maternal and child health, reproductive health, aging, and social, environmental, and occupational determinants of health, that puts LMICs in a particularly challenging situation.

Hence, there is a strong need for a systemic and integrated response to the current needs of healthcare systems in developing countries that are often focused on short-term care rather than long-term care and preventive measures. As a result, with cases of multiple comorbidities occurring more frequently, there is an increasing demand for high-quality healthcare and long-term solutions.

2 What Digital Health Can Bring to the Table

Numerous forces worldwide have been driving significant changes in healthcare towards a consumer-centric digital health model: shifting demographics, consumer and patient demand and expectations, financial burden, the inefficiency of legacy healthcare infrastructure, and most importantly, availability of and advances in digital technologies that have become essential for daily life. This is particularly true in Asia as it is now undergoing the more prevalent Asian Century, with the larger economies becoming stronger global players. At the same time, other countries are moving up to become MICs and LMICs, such as Vietnam, and the aforementioned factors are reaching new heights in the region. In 2021, it was estimated that digital health impacts more than a billion lives and could create up to $100 billion in value in Asia by 2025.⁸

With the rapid development of digital technologies, there are more and more applications to every aspect of health and healthcare, leading to the umbrella term of digital health, that encompasses eHealth, health information technology (health IT), mobile health (mHealth), wearable devices, telemedicine and telehealth, and precise and personalized medicine, among others.

Health IT refers to the general use of hardware, software, and other electronic infrastructures to process, store, manage, and exchange health information (clinical, administrative, and financial) between patients, providers, payers, and quality monitors. Electronic Health Records (EHR) go beyond Electronic Medical Records (EMR) as the latter is principally a digital version of the traditional paper charts, keeping all the medical and treatment history of the patients in one practice. In contrast, the former goes beyond encompassing the patient’s total health to provide an inclusive perspective on the patient’s care and health status that can be shared with the whole healthcare ecosystem. With the high penetration of devices such as smartphones, tablets, etc., and their capabilities, it is evident that mobile communication technology is leveraged for healthcare: patients’ self-care through health apps, real-time monitoring, collection of clinical health data, exchange of healthcare information, training and collaboration of health workers. Branching from mobile health (as wearable devices are often connected to mobile devices, using the Internet of Technology (IoT) solutions), these devices are used to collect, transmit, and analyze personal health data through smart sensors: fitness trackers, smart watches, ECG monitors, blood pressure monitors, biosensors, etc. Telemedicine and telehealth, representing remote clinical services and the broader scope of remote healthcare (including non-clinical services), respectively, use digital information and communication technologies to access and deliver healthcare services remotely without any in-person visits, and were particularly useful during the COVID-19 pandemic. Telemedicine can improve access to rural, remote, and marginalized communities, and along with e-pharmacy services, can broaden access to primary care for underserved populations and maintain continuity of care. Precision and personalized medicine leverages genomics, big data analytics, and population health to help clinical decisions for disease prevention, diagnosis, and treatment for a more accurate, precise, proactive, and impactful outcome. Digital tools facilitate personalized healthcare through data-rich decision-making based on a comprehensive history and follow-up in many healthcare touchpoints. It sits at the forefront of being a consumer-centric digital solution while promising better approaches to diseases such as cancer, neurodegenerative diseases, and rare genetic conditions.

Digital health ecosystems are built to be consumer-centric by bringing together a network of healthcare providers, applying digital tools to analyze patients’ needs and direct them toward the appropriate provider based on their behavioral, social, and health data, all supported by digital technologies that enable the exchange of information between healthcare providers. Indeed, using digital health applications, patients and their healthcare providers can cooperate in a consistent and ongoing healthcare process toward seamless and cost-effective medical care without lining up in a crowded waiting room or missing the golden periods of diagnosis and treatment. By reducing the fragmentation of care, digital health solutions improve patient safety and quality of care. More significantly, with a health-related database, policymakers and providers can leverage real-time information to enhance the quality of healthcare and better understand the current health situation in the population and, hence, the disease burden.

According to WHO and UNDP, digital technologies have proven potential to deliver better patient care and enhance health outcomes through better medical diagnosis, data-based treatment decisions, digital therapeutics, clinical trials, self-management of care and patient-centered care; increased revenue for health centers; more quality data for policy and decision-makers; reduced cost for patients; development of health workers through e-learning by creating more evidence-based knowledge, skills and competence; all while striving to provide equitable and universal access, with quality that is cost-effective and affordable.^9,10

In facing a shifting disease burden and a double burden, as seen in the case of LMICs, shortcomings are exposed in relation to healthcare systems due to weak infrastructures and a lack of resources, leaving them unprepared for long-term care and preventive measures as the focus remains on short-term care due to the current and recent history of dealing mainly with communicable diseases, and these challenges are further aggravated by the lack of accessible quality healthcare.

One of the most significant weaknesses of healthcare systems in LMICs is infrastructure, resulting in a state of unpreparedness when faced with the double burden. Clinical settings are typically centralized in urban, populated areas with comparatively higher-income populations, which limits access to high-quality healthcare services and leads to inequality. The cost of transportation and follow-up due to distance breaks healthcare provider and patient connections in most cases. Without following up, NCDs become unmanageable, leading to life-threatening complications. Also, without interactions between medical staff and patients, trustworthiness and engagement cannot be built. Telemedicine solves the long commute issue, saves patients’ time and money, and reduces pressure on overcrowded hospitals. With a strong network of hospitals equipped with telehealth, high-quality healthcare can be centralized in critical areas and accessed remotely on demand. Virtual consultations and remote patient monitoring demonstrated their usefulness in COVID-19 time and can be expanded into many infectious disease management programs to timely respond against communicable diseases by effectively limiting human-human contact. However, LMICs struggle due to limited resources, further aggravated by the double burden. It is challenging for them to build a sustainable healthcare system that can be highly efficient and help with cost-saving, and could then free resources for better allocation. This is where digital health solutions can help reduce costs, that becomes particularly significant in the long term. For example, health IT systems such as an EHR will help healthcare providers access patient data quickly, improving efficiency and reducing costs while standardizing the flow of information in the entire healthcare ecosystem, enabling a holistic perspective on the patient’s health. With the patient’s history available for the physician, a long-term patient-physician relationship is quickly built, with new information being integrated at each step, helping early recognition of problems before possible health issues become unmanageable, leading to unnecessary spending by patients and a strained workforce for healthcare providers.

The challenges that come from the double burden of disease can be addressed by digital health solutions in both of its two core components. Communicable diseases normally require acute care with expediting access but limited transportation and human contacts. The COVID-19 pandemic proved the power of digital tools in sharing information and communication, tracing contacts and mapping cluster development, supporting healthcare services, and accelerating the development and implementation of vaccination programs. Data collected can be used for epidemic control and disease model prediction, helping national, regional, and international collaborative efforts in eradicating communicable diseases. NCDs, on the other hand, need high-quality care over time by closely monitoring patients’ health, engaging patients in treatment courses, and in many cases, modifying and engaging patient behavior towards wellness. There are many digital chronic disease management platforms that provide services to manage patients’ conditions, home-based lab services, e-pharmacy services, and medicine taking. In terms of prevention, mobile apps with health devices can track customers’ daily step counts, food consumption, heart rates, blood oxygen level, etc. Recommendations for better routines, changes in behavior, or early detection of abnormalities are available to improve wellness. As targeted by WHO, digital health has the potential to help achieve important goals by prioritizing and supporting the prevention and control of NCDs at all levels through international cooperation, which is facilitated through better data sharing and exchange. In turn, this strengthens the global, regional, and national agendas, building partnerships across sectors and collaborating in their efforts. It can also enhance healthcare systems and create health-promoting environments for better cooperation between healthcare providers and patients, leading to monitoring NCD trends and determinants.

Digital tools can help reduce disease burden through prevention by promoting wellness. Wearable devices give personalized recommendations on healthy routines and keep track over a long period of time to shape good behaviors. Moreover, health-support devices facilitate an early warning system for prevention and detecting abnormalities, which is the key to the early diagnosis of diseases. By detecting changes to an individual’s health status very early, they improve therapy outcomes, save costs and resources, prevent hospitalization, and relieve the burden on healthcare systems. For people at risk of cardiovascular events, early detection of abnormalities in asymptomatic individuals can prevent premature death, heart failure, or ischemic stroke.¹¹ Supporting diagnosis at an early stage, many AI-augmented diagnostic tools are used by physicians and health technicians to quickly and precisely catch the damages and show their use cases in improving treatment outcomes and reducing the economic burden. Furthermore, advanced diagnosis tools can effectively manage symptoms that are beyond the average level of physicians’ skills, resulting in improved clinical performance and greater accessibility to optimal healthcare for all patients. This can also alleviate the workload of the healthcare workforce and decrease disparities in their proficiency capabilities, which improves the service quality.

Digital health promises to alleviate the strain on healthcare ecosystems while providing holistic perspectives and improvements, leading WHO to harness its potential “to accelerate global attainment of health and wellbeing.”¹²

At the micro level, the advancements and implementation of digital health solutions allow for a better insight into the social, behavioral, and environmental determinants of health, providing healthcare providers with a greater understanding of individual preferences, values, interactions, and exposures. This can create long-term partnerships for creating healthy behaviors and environments while delivering targeted preventive and acute care for better health outcomes. As this valuable information and data circulate safely and securely within the healthcare system, from healthcare providers to commercial players, insurance companies, and governmental agencies, it becomes possible to go beyond health behavior and self-awareness to provide on-demand health information and education, and promote accountability with social support networks, health coaches, and providers.

When such digital health solutions are equitably implemented and effectively used at the macro level, they can help prevent, mitigate, and reduce inequalities in access, quality, and cost. For healthcare providers, knowledge transfer and management become more feasible, improving the workforce’s skills and capabilities, thus upgrading the overall infrastructure and resources. In addition, the aforementioned data can provide analysis into identifying behavioral risks, monitoring patterns and trends of diseases for evaluation and understanding of the relative importance of disease and disability for the entire population, and a better understanding of which condition poses the more significant threat to society, allowing policymakers and public health practitioners to allocate resources optimally for better health outcomes.

3 The Case of Vietnam

Vietnam, the world’s 38th largest economy (according to GDP in current prices, as of October 2022¹³), is one of the countries successfully transitioning from being amongst the poorest nations into a LMIC, resulting from the Đổi Mới reforms of 1986 that opened up the economy to the international market and trade. Since then, the country has experienced rapid economic development, a growing population, poverty alleviation, and an increasing share of the middle class as the nation reached LMIC status in 2009. Over the last two decades, pre-COVID-19, it enjoyed an average annual GDP growth rate of 6.5%,¹⁴ and emerging from this pandemic crisis, its GDP grew by 8.02% in 2022. With a population of 98 million people in 2021, Vietnam is the 15th most populated country in the world and currently benefits from its demographic status of a golden population structure, with 70% of the population being of working age (18–65 years old) (Fig. 4), contributing to its economic development. The country’s rising living standards have increased life expectancy at birth to 75 years.¹⁵ However, population growth is now floating at 0.8% per year,¹⁶ leading to an aging population since 2015. Vietnam is among the fastest aging countries, with an expected shift towards an aged population from 2035 onwards.¹⁷

Fig. 4

Vietnam population age structure, 2023. (Source: Population Forecasting, IHME Viz Hub (healthdata.org))

Rising living standards and the population structure brought an essential shift in its healthcare landscape and increased healthcare expenditures due to surging demand for high-quality healthcare and private healthcare providers, namely by the strong middle-income class; but in the longer term, the healthcare structure will be tested as the population ages. Another factor behind this shift in the healthcare landscape, which is also impacted by the country’s economic development, is the shifting disease burden from communicable diseases to NCDs, that requires long-term healthcare solutions. The substantial increase in NCDs is due to people increasingly adopting unhealthy habits: from a sedentary lifestyle due to urbanization, decreasing levels of physical activity due to new transportation forms such as motorbikes, dietary changes due to the globalization of fast food, and high levels of smoking tobacco and drinking alcohol. For example, in 2018, the total alcohol consumption per capita (liters of pure alcohol consumed by 15+ years of age) was 8.7 liters, and in 2020, 24.8% of the population aged 15 years or older smoked tobacco on a daily or non-daily basis.

As a result of its economic development, Vietnam has experienced rapid advances in technology and the country’s overall infrastructure has improved. The entire population has access to electricity, 73.2% is connected to the internet through 156 million cellular mobile connections (a single individual may have more than a single subscription) with an average median download speed of 35.14 Mbps. Amongst internet users (between the age of 16 to 64), 97.6% own a smartphone, 64% own a laptop/desktop computer, 35.2% own a tablet, 29.9% own a smartwatch/wristband, and 18.6% own a smart home device. This same part of the population also spends an average of 6 h 38 m using the internet, with 76.95 million active social media users spending an average of 2 h 28 m on social media.¹⁸ This demonstrates the digital literacy of the Vietnamese population and how the internet is core in both daily life and across all sectors, laying solid foundations for digital development and adoption of innovative technologies. In parallel, Vietnam is pursuing rapid growth in mobile communications technologies while shifting towards cloud-based services, moving toward becoming a digital nation by 2030. This is set out by the National Programme for Digital Transformation’s aim to “develop a digital government, digital economy, and digital society and to establish Vietnamese digital technology enterprises capable of going global,” as declared by the Prime Minister of Vietnam in 2020. The objective is to become one of the 30 leading digital nations in the world, driving forward Vietnam’s socio-economic development and national competitiveness through innovation, and it is expected that such goals will have a significant impact on the development of digital health solutions.

However, the country is still facing challenges of multidimensional inequalities, categorized into four different areas, that are interrelated: income and asset, life and health, education and learning, participation, influence, and voice. Focusing on the first three areas (due to their significant impact on health) based on a report by Oxfam,¹⁹ as of 2016, wage inequality accounts for the largest share at 46.2% of total income inequality. In contrast, for total consumption inequality, it was mostly non-food consumption and housing. A significant disparity in all areas is due to the substantial gap in living standards between the Kinh (the largest population in Vietnam) and ethnic minorities (EMs): EMs account only for 15% of the total population but represent 73% of the poor.

Regarding life and health, inequality is differentiated by ethnic groups, regions, and income groups due to four main drivers. First, there is unequal access to healthcare due to the distance to healthcare centers for high-quality care, and a lack of healthcare providers (0.82 physicians and 1.34 nurses per 1000 residents). Second, despite impressive progress, there remains unequal access to maternal and child healthcare, with child mortality rates varying significantly depending on the region. Third, poor households have unequal access to clean water, adequate sanitation, and good nutrition, especially in densely populated areas with EMs, raising the risks of communicable diseases spreading. Finally, social and cultural norms influence many practices, negatively impacting their health and living standards.

Government expenditure and external financial support for healthcare have tended to decrease over time, and the Vietnamese government has gradually reduced funding for public hospitals, making them financially autonomous. During COVID-19, medical facilities were overcrowded, and resources stretched thin, overloading the entire healthcare system. As such, inequality issues can potentially disrupt the continuity and consolidation of developments and achievements made in healthcare in the past years. It should be noted that the healthcare system in Vietnam, from primary to tertiary, is structured by four administrative levels: commune (health centers from both public and private sectors), district (general hospitals and preventative health centers from both public and private sectors), provincial (general and specialty hospitals, preventive health centers, from both public sectors, and secondary medical schools), and national (general and specialty hospitals, preventative health centers, from both public and private sectors, and medical and pharmaceutical universities and colleges).

With compulsory education in primary school only, the enrolment rate starts to drop at higher levels, including high school and college. Urban areas have a significantly larger enrolment rate than rural areas, 51.8% compared to 33.6%, and the enrolment rate also has a strong correlation with the education level of the household head and the household’s economic status, namely for EMs. On the other hand, the quality of infrastructure, facilities, equipment, and teaching activity varies greatly depending on regions, even between the main site and the satellite site of the same school, with poorer conditions being prevalent in geographical locations mainly occupied by EMs.

With such solid developments and existing inequality, Vietnam is a prime LMIC where digital health solutions offer opportunities to advance the healthcare ecosystem further and improve health outcomes of the population in general.

3.1 Toward a More High-Income Patient Profile

Boosted by the country’s socio-economic development, the middle class has grown significantly in Vietnam and is expected to continue growing, from 10% of the population in 2015 to an estimated 50% by 2035.²⁰ This growing middle class, along with its rising living standards, is also correlated with the increase in digital literacy and results in a greater demand for high-quality healthcare, private healthcare providers, and the incorporation of digital health services.

Leveraging the development of infrastructure and in response to the demand, private hospital networks have seen rapid growth, with some hospital chains such as Hoan My and Vinmec also achieving international standards such as Joint Commission International (JCI) accreditation. As these hospitals use more advanced health management systems and deliver advanced digital health solutions, high-income patients increasingly adopt digital health for better healthcare outcomes. Patients’ trust in such services increases over time upon satisfaction with the quality, guaranteed through transparent governance and improving the local standards to international best practices. In parallel, digital tools also enable better patient engagement and trust, with more and improved direct communication between patients and healthcare providers, telemedicine, and encrypted EHR. Even public hospitals have started adopting digital health solutions, enhancing operational efficiency and medical outcomes, with more than 92% of them outsourcing to local IT companies such as FPT, Link Toan Cau, and Dang Quang to develop digital solutions for their facilities.

Telemedicine is beneficial because it alleviates the strain on physical medical infrastructure and avoids the spread of infections. It also allows patients more freedom with the timing and location of their consultations which is particularly advantageous if they have tight schedules due to their occupations. It avoids draining the resources of the provincial and national hospitals, resulting in better efficiency and cost-saving, as the Vietnamese strongly prefer these hospitals over communal health centers that remain highly underutilized. As resources are better allocated to new tools to track health outcomes for long-term healthcare in a move away from short-term care due to the shifting disease burden, high-income patients’ demand is growing for better interventions for faster recovery, preventive solutions, and wellbeing in general. Precision and personalized medicine, leveraging AI and ML technologies, deliver early screening of possible health risks by combining genomic data and clinical histories, offering rapid treatments at early stages, and promoting behavioral change for better health outcomes.

Nevertheless, with the local healthcare sector experiencing capacity constraints and sometimes unable to provide the standards demanded by high-income patients, a significant portion of these opt for healthcare solutions in other countries, such as Thailand, Malaysia, Singapore, Japan, or the United States of America. The main reasons why patients choose treatment abroad include the healthcare quality and service, the qualification and experience of the healthcare professionals, the availability of medicines and treatments, and the reputation of healthcare facilities. The amount spent on medical tourism amounts to two billion USD yearly.

Given the opportunities from socio-economic and technological development and facing the challenges of a double burden and inequality, Vietnam is now in a prime position to adopt digital health solutions to meet the increasing healthcare needs of the population, to face the double burden, and provide equitable and universal access, with high quality that is both cost-effective for providers and affordable for patients. This has led the Government to set out an agenda for bringing digital transformation to its healthcare industry, working in a quadruple helix model (government, businesses, academic institutions, and society) that makes up the entire healthcare ecosystem.

3.2 Local Digital Health Solutions: Indicative Examples

Various local players, from private healthcare providers to universities, startups, and offshore software developers, have taken advantage of the favorable factors resulting from the strong socio-economic and technological developments to develop digital health solutions for both the local and foreign markets, ranging across numerous aspects of the healthcare system. While many digital health solutions already exist in the market (often from HICs), they are often too costly for local implementation and integration in the local healthcare ecosystem remains challenging without compatible infrastructures.

Many mobile applications are used for tracing and monitoring infections to help control and prevent outbreaks of communicable and infectious diseases, e.g., COVID-19 with Bluezone and Ncovi (Vietnam’s medical communication information system), and support HIV-infected people committed with antiretroviral (ARV) treatment. In addition, messaging services such as Messenger, WhatsApp, Viber, Zalo, etc., have been used for low-cost options to monitor diarrhea and influenza or update the COVID-19 pandemic status. Meanwhile, high-quality and advanced healthcare systems have been established to provide more precise and personalized medicine, and are gradually marking the transition towards preventive healthcare and wellbeing in order to better cope with NCDs.

3.2.1 VieVie Healthcare Co., Ltd: Telemedicine for Diagnosis and Patient Care Management

VieVie Healthcare Co., Ltd is a telemedicine company that was launched in 2017, with investment by Clermont Group (a private investment group based in Singapore), which also owns the Hoan My Medical Corporation, one of the largest private healthcare networks in Vietnam. Through the partnership between VieVie and Hoan My Medical Corporation, the former’s digital health services and solutions are fully integrated into the hospital network. VieVie offers an online telemedicine platform established as a marketplace that connects both patients and doctors: providing space for patients to communicate with doctors for video call consultations and other primary care services, while doctors can expand their portfolio by signing up on the portal.

Like other telemedicine platforms around the world, this solution proved its efficiency during the COVID-19 pandemic by limiting human-to-human contact and alleviating crowding and constraints in hospitals while maintaining healthcare activities remotely, in turn promoting accessibility.

3.2.2 Hanoi Medical University Hospital (HMUH): Telehealth in Action

The Hanoi Medical University is the oldest modern university in Vietnam, founded in 1902 by the French during the French colonization, and it is now the most prestigious medical university in the country. Stemming from its long history, the university and its hospital enjoy a vast depth and breadth of knowledge and practice rooted in excellence.

During the COVID-19 pandemic, HMUH showed strong initiative in digital health solutions by being the first to launch a telehealth program on April 18th 2020. By leveraging its educational roots and live streaming on Facebook and YouTube, it provided free education, open and accessible for everyone, to raise awareness about COVID-19, getting people working together and learning from each other. With more centers joining such activities, learning becomes more beneficial through network effects, raising awareness of the pandemic (and of communicable and infectious diseases in general), and helping to bring it under control.

As Vietnam lacks medical resources, the disparity in medical examination and treatment qualifications between commune/district and provincial/national poses a difficult problem for the Vietnamese health sector. Provincial and national hospitals are overloaded whereas commune and district doctors have little opportunity to improve their professional qualifications because of a lack of patients. Expanding telehealth to clinical services will enable experts from provincial and national hospitals to give advice in real-time on difficult cases that cannot be reached in district hospitals as immediate medical response is needed. This helps to mitigate complications and risks while saving time. As collaborative work becomes feasible, local healthcare providers can learn from experts, improving their knowledge and experience and improving patients’ trust in local healthcare facilities. This will reduce overcrowding in the larger hospitals and help the experts have more time to research new knowledge and advanced treatments, corresponding to the shifting disease burden. For doctors, every telehealth session is a valuable clinical learning session. Each online medical examination has thousands of viewers and tens of thousands of reviewers. Because of the apparent benefits, HMUH intends to implement Continuous Medical Education (CME) via telehealth and obtain permission from the Ministry of Health to issue a CME certificate for each telehealth session. This will be the simplest and most effective way for doctors to learn, especially young doctors, and will help raise the general standard of the entire healthcare ecosystem.

3.2.3 Finizz: Outpatient Clinics and Health Tech

Finizz is a startup founded in 2015 in Ho Chi Minh City as a platform for booking consultations, aiming to address the lack of information in the Vietnamese healthcare industry, and connecting people in need with healthcare providers. With over 30,000 medical facilities registered in the country, the platform generates thousands of monthly appointments for healthcare and beauty care in a highly efficient manner. In addition, the platform provides information on clinics, doctors, hospitals, diseases, drugs, etc., that is constantly updated for the best accuracy possible. To satisfy diverse search needs, this is complemented by a 24/7 online question-answering service. As people move into the middle class, less concerned by communicable diseases but facing more NCDs, information becomes crucial for increased awareness and healthcare engagement. Having more accessible information is one step towards dealing with the double burden.

3.2.4 BuyMed & Thuocsi: Pharmaceutical Supply Chain

In Vietnam, pharmacies commonly operate by purchasing drugs from unlicensed agents. This poses great risks for the whole healthcare ecosystem, consumers, and patients. As a result, healthcare providers often spend a great amount of time sourcing drugs, which further aggravates the problems due to lack of resources when dealing with health issues.

BuyMed, founded in 2017, tackles this issue as a business-to-business (B2B) pharmaceutical distribution marketplace, leveraging technology to solve fraud issues and promote verification in pharmaceutical supplies. It has connected over 2000 healthcare providers with verified suppliers. Thuosci.vn, founded in 2018, is one of the most successful startups in medical technology and services, operating as a platform that includes a website and mobile application for providing and distributing drugs and pharmaceuticals to more than 1000 pharmacies and clinics across the country. Building on its success, it is currently expanding its distribution network further to neighboring countries in South-east Asia, such as Cambodia.

3.2.5 mHealth for Increasing Immunization Rates at Low Cost in Vietnam

Low rates of completed childhood immunization can be a major health issue that can escalate with time, affecting the burden of disease and the general population health. Although Vietnam claims a high immunization coverage rate of 95% (based on the diphtheria-tetanus-pertussis (DTP3) vaccine as a key indicator of immunization program performance), the system is highly inefficient due to its reliance on a paper-based system to administer, monitor, and report vaccines and immunizations. This also leads to possible errors in data recording and reporting, potentially impacting vaccine stocks, resulting in a child missing a vaccine and contracting a disease that could have been prevented. Hence the actual immunization coverage rate may not be accurate at regional levels.

A digital solution was developed in 2012 called the Digital Immunization Registry System (ImmReg) to replace the old paper-based system. ImmReg is a web-based application (for both computers and mobile phones) that tracks the vaccination status of children, and in which immunization data can be recorded and accessed in real-time. With the addition of an auto-SMS system integrated in 2017 (in cooperation with Vietel and taking advantage of the growth of mobile networks for mHealth) , reminders can be sent via SMS to caretakers for the required vaccinations to be administered on time. As a result, workload burden is reduced, cost-saving is increased, data recording accuracy is improved, and most importantly, immunization rates and timing are improved. With a strengthened quality and effectiveness of immunization programs, it will be beneficial for the healthcare system to integrate this system into the national health IT and adopt it for other healthcare programs (i.e., maternal and child health, nutrition or infectious disease control), boosting overall efficiency and minimalizing health issues that can be prevented by vaccines.

3.2.6 Ominext Joint Stock Company: Promoting Primary Care

By digitizing the medical and healthcare systems, the information technology system is fundamental for moving away from analog and legacy approaches.²¹ Ominext Group²² brings a holistic and integrated expertise capable of developing and implementing various systems for areas related to hospitals & clinics, treatment & examination, medicine, welfare, and patient services, all as a cost-effective, project-based, and labor outsourcing development solution.

Established as an offshore software development company providing mainly for the Japanese market, the group has been able to provide for the needs of the Japanese market with its aging population and digital transformation efforts in all industries, by building on the ability to provide outsourced software development at a cheaper cost against high labor costs and a shortage of skilled workforce in Japan. There are three main factors contributing to Japanese longevity: equity, the government’s strong intervention, and universal health coverage. With the country pushing for the concept of Society 5.0, Japan’s digital health is technology-based, human-centered, and aims for wellness and personalization. The group integrates its extensive knowledge of medical and healthcare systems with technology systems ranging from cloud systems, big data, server and system development and maintenance, image analysis, IoT, and AI to blockchain, leading to the development and deployment of over 250 systems in over 7000 hospitals/clinics and 3000 pharmacies, all in alignment with security and regulatory frameworks, from ISO to Japanese governmental guidelines.

Since 2018, with advances in the digitization of the medical & healthcare industry in Vietnam, Ominext Group has expanded its operations locally in Vietnam through its subsidiaries to provide medical & healthcare services by creating a safe, modern, and reliable healthcare ecosystem. With Ominext’s knowledge and experience from having operated in Japan, building a thorough understanding of the healthcare ecosystem and health situation in a highly developed country, it can bring valuable insights to a developing country like Vietnam, helping prepare for the future of health as the country pursues its growth and deals with the shifting disease burden.

3.2.7 Institute of Gastroenterology and Hepatology

Institute of Gastroenterology and Hepatology (IGH), established in March 2018, is a scientific and technological organization for intensive research and training in digestive and hepatobiliary issues. In adopting a patient-oriented, digital health solution, IGH opts for mHealth through mobile applications, such as GERDcare or a colonoscopy bowel preparation application, to help bridge the gap between physicians’ instructions and patients.

For digital health solutions that are doctor-oriented, AI tools can be used for clinical diagnosis in a move towards high-quality precise and personalized medicine. Commercial products already exist (Fuji Film and Medtronic), but tend to be costly and require compatible infrastructure from the same providers, and need continuous updates. With resources already limited, it is more viable for institutions to develop their own in-house solutions as the development can be controlled and the technology owned, providing flexibility in integration and decoupling and, most importantly, reducing the cost for primary care facilities. Such projects begin with building a database from scratch, with big data from and for Vietnamese people, training the system to tag possible issues for diagnosis while promoting ongoing communication between the IT and data science teams. The collected data will be used for further studies and educational purposes, supporting primary care. However, there are important challenges: building the database is time-consuming (1 year for setting up the standards and training for judgment), and resources remain limited, even for in-house development. While the side-product can be used for training programs, with the data being used for education and investigation, the whole study remains at a very early stage.

3.2.8 Vinmec

Vinmec is a non-profit healthcare system established in 2012 as a subsidiary of Vingroup (the largest conglomerate in Vietnam). It currently operates seven international-standard hospitals. With the aim to improve patient outcomes and advance healthcare in Vietnam, Vinmec has been working to continuously deliver international standards through advanced healthcare models, research, and embraced digitization to improve and create new solutions that also correspond to the increasing consumer demand.

To deliver a value-based and patient-centric care, Vinmec implemented P4 medicine, with the emphasis on personalized, predictive, preventive, and participatory care, employing various digital tools, such as AI and big data, for advanced healthcare activities that include genetic testing and molecular diagnosis. These practices enable the tailoring of treatments for individual patients, a desirable procedure for high-income patients and for better healthcare outcomes in tackling NCDs in particular.

To support the management, research, and services, Vinmec has undergone significant digital transformation. A notable example is its in-house developed mobile application, MyVinmec, to provide patients with a convenient healthcare experience, from booking appointments to telehealth, medical records, test results, and prescription refills. Reducing waiting times and improving patient engagement, it enables patients to track their longitudinal medical history, marking the transition from looking after illnesses and their treatment to preventive care and wellbeing. Meanwhile, for the practitioners, this increases efficiency and alleviates resources, allowing better focus on other advanced healthcare activities. In addition, the hospital group has adopted a picture archiving and communication system (PACS) to digitize the traditional films, providing instant access to medical images, which coupled with AI-assisted X-ray diagnostics, helps diagnose conditions rapidly and accurately. Outside of these two major actors, Vinmec has also established a digital connection with healthcare insurance providers, allowing insurance claims to be processed directly in less than an hour, further boosting the efficiency for all stakeholders.

4 Conclusion

LICs and LMICs face a particular set of interrelated challenges. Despite the socio-economic development they may be enjoying, strong inequalities persist on many levels that tend to impact the population’s health negatively. The general healthcare ecosystem remains underdeveloped, with a weak infrastructure and a lack of resources. On the other hand, due to various drivers, the countries experience a shifting disease burden, with an increase in NCDs while communicable diseases remain prevalent, leading to a double burden. In turn, this double burden adds pressure to the already strained healthcare ecosystem, stretching resources thin and challenging the infrastructures. The result is that healthcare providers and policymakers will be unable to get the best results when tackling the double burden, which is the central issue. This will fuel further inequalities, which may ultimately impede socio-economic development. This situation may result in a vicious cycle that worsens the situation on all fronts.

Fortunately, other factors exist that can help avoid such a vicious cycle by alleviating these difficulties. Many of these will be fueled by digital health that offers various solutions to help tackle the shifting disease burden and double burden, while improving the healthcare ecosystem and responding to the increasing demands of customers and patients. These solutions help provide equitable and universal access to quality healthcare, that are both cost-effective and affordable, and can turn the potentially vicious cycle into a virtuous cycle, leading to further socio-economic growth. It was for this reason that indicative examples were presented in this chapter, these are not the only ones that exist but are used simply to illustrate the point.

For this to become a practical reality, it is essential to first gain a deep understanding of the health inequalities and how digital health may prevail in this area. In the next chapter we will explore this theme in more depth.