Globally, detailed data and metadata on past and ongoing projects, initiatives, stakeholders, outcomes, standards, lessons learnt, and knowledge in digital health are available in a fragmented manner. This impedes the ability to have an accurate and reliable picture of digital health landscape, and thus making evidence-based decisions. Having easy access to this information on a single platform provides a comprehensive understanding in a global context, while ensuring coherence and sustainability with respect to the broader health system.

The gdhub, which was developed in partnership with the Swiss Agency for Development and Cooperation and hosted by the University of Geneva, aims to provide a remedy to this fragmentation. In 2022, the University of Geneva created a web-based app called ‘Implementome’ to serve as a dynamic knowledge database encompassing various dimensions such as individuals, undertakings, publications, evaluations, experiences, and proof associated with digital healthcare implementation. The goal of Implementome is to strengthen the bond among stakeholders involved in the digital health domain by tapping into their skills and knowledge, fostering collaborative processes, facilitating decision-making, and offering a seamless view of the overall digital health ecosystem.

For the application, dHRC in collaboration with Aga Khan Health Service, East Africa, conducted in-depth mapping and dissemination activities for the Implementome through a series of workshops in September and December 2022. The aim was to engage stakeholders, validate information on ongoing digital health projects, products, organizations and individuals in Kenya, introduce the Implementome to key stakeholders and disseminate information on findings of the mapping activity. The final workshop, with government stakeholders, aimed to understand the potential impact of the information available through Implementome on funders, implementers and government authorities.

About Implementome
The Implementome, available on the Google Play Store, can be explored and enriched both by humans and by AI-enabled automated processes. The tool provides valuable knowledge, guidance, connection, and necessary collaboration. The long-term goal is to unlock the full potential of digital health for efficient, equitable, and high-quality health systems by using Implementome as a one-stop shop for digital health collaboration and implementation.

The project was funded by the University of Geneva and implemented by dHRC in collaboration with the Aga Khan Health Service, East Africa.

Looking at Abdullah Ali now, it’s hard to believe he suffered a chronic skin condition only a month ago. After a shaky end to the year, the 16-year-old is in good health and good spirits today.

Abdullah, who lives in Follady, Dare Saadat, Bamiyan, Afghanistan, had been struggling with a persistent scalp rash for several weeks. Despite his efforts, his condition only seemed to be getting worse, and he was becoming increasingly self-conscious about his appearance, which was affecting his mental health.

In November 2022, Abdullah, along with his family, decided to travel a distance of 35 km from his home to the Bamyan Provincial Hospital, which is a spoke site for teleconsultations. A teleconsultation was scheduled between Dr. Mohmmad Qasem, Medicine Specialist at the Follady CHC and Dr. Hayatullah Shalizie, Dermatologist, at the hub site, the French Medical Institute for Mothers and Children in Kabul.

After assessment, Abdullah was diagnosed with Psoriasis, a chronic skin condition that affects approximately 2-3% of the global population. Sayez Reza displayed signs of red, scaly patches on his scalp, which were itchy and extremely painful.

A follow-up visit was held in January 2023, after which Abdullah was able to successfully manage the rash on his scalp and his confidence begin to return gradually.

Through the AKDN Digital Health Program, Abdullah was able to receive the care he needed without having to travel long distances.

The climate of Afghanistan is generally arid or semi-arid, with hot summers and cold winters. The combination of environmental and cultural factors in Afghanistan can contribute to dry, itchy skin, resulting in skin conditions. In addition, dust and other air pollutants can contribute to the development of skin disorders such as acne, rosacea, and allergic contact dermatitis.

Abdullah’s story is a powerful testament to the role that telemedicine can play in improving access to care and health outcomes, especially for people who live in rural areas who have limited access to specialist health care services.

This is the story of Afsana Karomatullo, a 54 year-old female, living in Porshinev, Pashor Village of Tajikistan.

Afsana had been ill since 2014 with Charcot-Marie-Tooth (CMT), a disease that is a relatively rare genetic disorder, which hadn’t been diagnosed. CMT affects an estimated 1 in 2,500 people worldwide, making it one of the most commonly inherited neurological disorders.

After nine years of suffering, she learned about the AKDN Digital Health Program in Tajikistan and travelled a distance of a mere 15 km from her home to the Aga Khan Medical Center, Khorog (AKMC, K), which is a spoke site for teleconsultations to avail services for her condition, in hopes that she may find a proper diagnosis and treatment.

Dr. Zubayda Aqdodova, Neurologist at AKMC, K conducted a teleconsultation with Dr. Rizwan Haroon Rashid, Consultant Orthopedic Surgeon and Dr. Tashfeen Ahmed, Orthopedician at the Aga Khan University Hospital (AKUH), Pakistan. They diagnosed the disease as CMT and prescribed lab and radiology tests to confirm whether she was eligible for a surgery. Thereafter, a surgical procedure was recommended.

During the consultation, Afsana described how her condition started to worsen when she was 45 years old. She was unable to walk because of the deformity in her right foot, so she resorted to walking on her knees. Additionally, she suffered with weakness in the lower extremities: including muscle weakness and wasting, especially in the legs and feet with difficulty in maintaining balance. She also had a surgery performed on right foot, however, there was no improvement. She also revealed that her brother and mother were suffering with the same hereditary disease (dystrophy).

Dr Rashid and Dr Ahmed provided their expertise for pre-surgical planning and a complex surgery (for the ankle deformity) that was conducted at AKUH, Pakistan. The operation was successful, and after several post-operative follow-up teleconsultations, she was able to find relief. The patient’s family is overjoyed with the results – she was able to walk on two feet after a decade. Dr Rashid and Dr Ahmed remotely assisted the doctors for securing implants.

“Now, my mother is able to do work at home without anybody’s help!”.

The cross-border teleconsultation services enabled the healthcare providers at AKMC, Khorog to perform the procedure, cost-effectively. The cost saved through teleconsultation services including accommodation, meals and doctor’s fee totals to approximately $1500!

“It is like the doctor is available in your own country. It went perfect.”

This success story how telemedicine is improving access to specialized care for patients, who lack access to quality health care, with rare or chronic conditions like CMT.

The COVID-Innovation Research Project (CIRP) aims to investigate the effectiveness of developing and scaling up three COVID-related digital health innovations in strengthening health systems and improving access to care in at-risk populations in select geographies in Afghanistan, Pakistan, Tajikistan, Kenya, Tanzania and for Arabic-speaking countries.

The study undertakes a multi-pronged applied research approach on the following three digital health innovations:

Overall, the study focuses on the extent of which these three digital health innovations are effective, feasible, usable and sustainable within health systems in target geographies. The initiative is based on incorporating these innovations in the healthcare systems through public-private partnerships (PPPs) with local and national health authorities.

During 2022, dHRC predominantly focused on maximizing the three applications’ reach across countries of implementation by promoting its use and capitalizing on opportunities to do so. Ethical approvals were attained in all countries and data collection was underway. Various promotional activities were carried out in the target geographies to increase uptake of the applications, including government involvement, marketing campaigns and trainings, among others.

The Results

The feasibility and user-acceptance of the three initiative was evaluated through three research studies evaluating PPEMA, VirtualDoc and CoronaCheck. The research studies found statistically significant rates of user satisfaction, self-reported knowledge improvement and self-reported behavior improvement across all countries. The results were particularly favorable for populations living and working in rural areas and informal settlements, suggesting a potential to reduce inequalities. The findings support the viability of mHealth as a medium for service provision particularly with the global trend towards remote care. They also suggest that mHealth provides a viable capacity-building platform particularly in remote areas of low- and middle-incomes countries, where training opportunities may be limited. Context-specific mobile apps with evidence-based content in local languages also have the potential to combat misinformation and disinformation and influence healthy behavior in populations of these LMICs.

CIRP is a two-year research project initiated in 2020 with research funding from the Government of Canada through the International Development Research Centre (IDRC) in Canada and the Aga Khan Foundation Canada (AKFC).

Hayat is a mobile application, which has been evidenced to improve coverage of and access to Reproductive, Maternal, Newborn, and Child Health (RMNCH) services, immunization, and child growth services, by digitalizing health worker operations. The Hayat application has successfully been implemented in select regions of Gilgit-Baltistan (GB) and Chitral Khyber Pakhtunkhwa (KPK), Pakistan since 2019 and is now being used by 1850 health workers. The innovation is designed to primarily benefit children under 2 years of age and women of reproductive age.

Research conducted in the project’s pilot and transition-to-scale found significant improvements in health worker attendance, satisfaction with services, and several maternal and child health output indicators, including vaccination and skilled birth attendance.

Evaluation Results
The project is currently in its final transition-to-scale phase (TTS4). It is a unique intervention that has been guided and informed by evidence throughout implementation stages. Research in TTS4 comprised cross-sectional surveys with key health system stakeholders across the health system, including decision-makers, and provincial and district-level managerial, administrative, and field staff.

Through this survey, the integration potential and sustainability of Hayat was evaluated. The survey assessed factors influencing Hayat's adoption in these areas through three categories: core readiness, technological readiness, and societal readiness. Core readiness examined the stakeholder needs, level of comfort and trust in the technology, and its compatibility with existing services. Technological readiness assessed the availability, affordability, hardware, and software requirements, capacity building, and physical access to Hayat. Societal readiness theme examined the interactions with other institutions in the region, sociocultural factors, inequities‎, and contextual relevance.

Evaluation findings indicate strong awareness of Hayat's potential impact in addressing needs and a commitment from the government to scale up digital technology infrastructure in these regions, which was previously hard to reach. However, there is limited awareness among policymakers and politicians regarding digital health solutions like Hayat. The political climate in Pakistan has been unstable, and although there are policies supporting technology use, there is limited implementation of policies. Additionally, while telemedicine is gaining popularity in support of its dissemination, there are still limited published standards for mHealth tools like Hayat.

Qualitative Findings
Hayat is also based on qualitative research findings conducted in 2020, which assessed the usability, operability, and task technology fit of the intervention for its long-term sustainability within the health system. Results from the qualitative assessments, which included focus group discussions and key informant interviews, helped refine the intervention’s scope, and the facilitators and barriers to its integration within the health systems.

“This is better than the manual procedure and no doubt, the timely information [it provides] is very helpful."
Vaccinator, Phandar, Gilgit-Baltistan

The findings indicated that health care providers in Pakistan appreciated using the Hayat app on their smartphones. It helped the health system by making it more reliable and transparent and providing better ways to track progress for the frontline workers and the clients. The findings further revealed that the app is easy to use for both the end users and stakeholders at the district level. The use of the platform has resulted in improved data quality and timeliness and helped enhance immunization coverage and maternal care through supportive supervision and monitoring of community health and lady health workers. The improved validity and reliability of data collected through the app have increased the confidence of health managers in their decision-making process.

“The data sharing process is improved specially the data of the LHW program. There are less chances of manipulation in the digitized system, and it will be much better if the whole data is digitized.”
EPI Coordinator, Gilgit-Baltistan

Further Scaling in Northern Pakistan
The Hayat platform has received strong support and demand from the health systems in GB and KPK, despite administrative and political challenges. The project has established partnerships at multiple tiers of the health system, and the platform has been upgraded for expansion into remote regions.

Due to the project’s successful implementation, encouraging results in improving health outcomes, and positive uptake by multiple tiers of the health system, the project currently being scaled in additional districts of Gilgit-Baltistan, including Astore, Diamer, Hunza, Skardu and Nagar.

The Department of Health, KPK has also requested to scale the Hayat across the remaining Union Councils of Chitral to cover Upper and Lower Chitral in its entirety. MOUs have been signed with both health departments regarding scaling and expansion of the innovation in respective regions.

Hayat has been implemented by the Aga Khan University in collaboration with Aga Khan Health Service, Pakistan and funded the Government of Canada, through the Grand Challenges Canada and the Aga Khan Foundation Canada.

In collaboration with the Aga Khan Health Service, Afghanistan (AKHS, A), dHRC is conducting a research study to explore the effectiveness of a digital health performance management tool, Sehatmandi, to strengthen the health system in Afghanistan. The Sehatmandi tool was designed, developed, and implemented in 190 government facilities, which were assigned to the AKHS, A, across the Bamyan and Badakhshan regions in Afghanistan to enhance the standard of healthcare provision.

The Sehatmandi tool was developed and implemented in 2019 to aid with the monitoring the performance of the assigned government health facilities. During 2022, a research study was undertaken by dHRC to determine the benefits and challenges as well as enablers and barriers to the app's adoption. The study is also focused on the viability and impact of the intervention's long-term sustainability and identifying design and scope factors that could improve its uptake.

During 2022, an MOU was signed between AKU and AKHS, A, ERC approval was obtained, while research data collection tools were developed, translated and verified. Plans for 2023 primarily field activities, including recruitment of staff and study participants, data collection and analysis, and dissemination of findings.

To read more about the Sehatmandi tool, visit the Sehatmandi application page.