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Abbreviations Used

ADB Asian Development Bank AI Artificial Intelligence

eDSS Electronic Drug Safety System

FDA Food and Drug Administration

ICT Information & Communication Technology

IT Information Technology ITU International Telecommunication Union

LEAP Licensing, Experimentation and Adaptation Programme

LMIC Low and middle income country

MOH Ministry of Health MSD Multi-stakeholder Dialogue

NGO Non-governmental organisation

NIHA National University of Singapore Initiative to Improve Health in Asia

PHMCA Private Hospitals and Medical Clinics Act PI Principal Investigator

PPE Public-Private Engagement PPP Public-Private Partnership

PRC People's Republic of China

PRISM-ScR

Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines for scoping reviews

ROI Return on Investment

SDG Sustainable Development Goal

SIL-Asia Standards and Interoperability Lab Asia

SMS Short Messaging Service

UK United Kingdom US United States

VC Venture Capitalist

WHO World Health Organisation

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Table of Contents

Table of Contents

Introduction ............................................................................................................... 4

Audience .........................................................................................................................8

Summary of Findings ....................................................................................................8

Methodology ........................................................................................................... 9

Findings................................................................................................................. 11

Facilitators of Effective Partnerships for Digital Health.......................................... 12

Barriers to Effective Partnerships for Digital Health ............................................... 16

Case Studies: Models of Digital Health Partnerships in Asia Pacific ........... 21

Case Study 1 : .............................................................................................................. 21

Singapore Ministry of Health - Regulatory Sandbox for Telemedicine ................. 21

Case 2 : Electronic Drug Safety System (eDSS) - Philippines’ first integrated national pharmaceutical information system ........................................................... 23

Case 3: Cross-sectoral partnership of Grameenphone Tonic in Bangladesh ..... 25

Case 4 : Asia eHealth Information Network (AeHIN) Standards & Interoperability Lab ................................................................................................................................. 27

Recommendations to Stakeholders .................................................................. 28

Fostering a Conducive Environment for Strong Partnerships ...................... 30

Have Your Say! ......................................................................................................... 34

Acknowledgements .................................................................................................. 35

Annex ..................................................................................................................... 37

Topic Guide for Key Informant Interview .................................................................. 37

Sources for Case Studies ........................................................................................... 38

PRISMA Search Flow Chart ........................................................................................ 39

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Introduction

Asia-Pacific health systems in the 21st century face many challenges including increasing health care costs, population growth, population ageing, increased burdens of non-communicable disease while concurrently still tackling high burdens of infectious disease, health workforce sustainability and growing patient demand. The region has seen increased internet and smartphone penetration, and using digital technologies, emerging markets have the opportunity to leapfrog the developed nations to provide quality, affordable, universal and patient-centric healthcare1. According to the World Health Organisation (WHO), digital health can be defined as “the use of digital, mobile and wireless technologies to support the achievement of health objectives. Digital health describes the general use of information and communication technologies for health and is inclusive of mHealth, eHealth as well as telemedicine” 2 . WHO defines eHealth as the use of information and communication technologies (ICT) for health while mHealth is defined as the use of mobile wireless technologies for public health. Another term used frequently is telemedicine, which WHO has broadly described as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”3. Digital health interventions can include various technologies, such as mobile applications, short messaging service (SMS), interactive voice response, health management information systems, mobile diagnostic devices, wearables, drones and big data analytics. Since 2005, the World Health Assembly (the governing body of the WHO), has recognised the potential of digital technologies to strengthen health systems and improve quality, safety and access to care, and encouraged WHO Member States to take action to incorporate eHealth into health systems and services through a series of resolutions and guidelines. Most recently, in April

1 The Digital Healthcare Leap , PwC https://www.pwc.com/gx/en/issues/high-growth-markets/assets/the-digital-healthcare-leap.pdf 2World Health Organization, Monitoring and Evaluating Digital Health Interventions: A practical guide to conducting research and assessment, WHO, Geneva, 2016 https://apps.who.int/iris/bitstream/handle/10665/252183/9789241511766-eng.pdf?sequence=1 3 WHO, Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth 2009. (Global Observatory for eHealth Series, 2)

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2019, WHO released its first guideline of digital health interventions for health systems strengthening4 Figure 1. Digital technologies and applications in the health system

Source: 2017 Ernst & Young AG in Broadband Commission Report , 2017 However, despite acknowledging the importance of digital technologies for health systems, data from 2015 reveals that although 87% of WHO Member States have some sort of mHealth initiative, only 58% have a digital health strategy in place

4 WHO guideline: recommendations on digital interventions for health system strengthening. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO.

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and only 55% have legislation to protect electronic patient data5. Global progress in digital health adoption and impact on health outcomes within and between countries has been uneven. Countries and/or marginalized populations who could benefit most from digital health initiatives are unfortunately the least likely to receive them. There have been several global level declarations from WHO and other global bodies calling for concrete action on integrating digital technologies into health systems but several challenges and barriers remain 6 . Challenges include unsustainable funding, high capital expenditures, limited workforce capacity and poor collaboration between the health and ICT sectors7. There is a rapid rise in players in the Asia-Pacific digital health sector but little evidence of how they are working together to create maximum impact. Many digital health enterprises are focused on wellness products for the healthy and wealthier segments of society. Multi-stakeholder partnerships are needed to move beyond disciplinary, institutional and corporate silos culture of “pilotitis8” to real, scalable public health impact. Evidence supporting the impact of multisectoral partnerships is growing, especially as countries try to achieve the United Nations Sustainable Development Goals (SDGs) that cut across sectors. Some of the world’s greatest health challenges will be solved only by the public sector working with the private sector, multilateral organisations, non-governmental organisations, and others9. The broad literature in the field of public policy has addressed the term “partnership” from a variety of perspectives; Brinkerhoff has defined partnerships as “dynamic relationships between diverse actors who share mutually agreed objectives and work together to achieve a common goal”10. Partnership has been identified as a SDG in itself and it is thought that a partnership approach rather than the contractual one, which has been the norm in the health ecosystem), will help achieve the best outcomes and increase ownership among partners 11 .

5 Global diffusion of eHealth: making universal health coverage achievable. Report of the third global survey on eHealth. Geneva: World Health Organization; 2016 6 Resolution on Digital Health, World Health Assembly 21 May 2018 http://apps.who.int/gb/ebwha/pdf_files/WHA71/A71_ACONF1-en.pdf 7 Digital Health: A Call for Government Leadership and Cooperation between ICT and Health, Broadband Commission, Feb 2017 8 The term ‘pilotitis’ has been used to express the frustration of many of those in the health sector at the continuing emphasis on demonstrating successful outcomes from narrowly focused interventions targeting relatively small populations. Many digital health interventions have succeeded in terms of adoption by a substantial number of providers and patients, however, have generally failed to gain the level of acceptance required for their integration into national health systems that would promote sustainability and population-wide application 9 Kuruvilla S. et al BMJ 2018;363:k4771 Business not as usual: how multisectoral collaboration can promote transformative change for health and sustainable development 10 Brinkerhoff DW, Brinkerhoff JM. Public–private partnerships: perspectives on purposes, publicness, and good governance. Public Adm Dev. 2011;31(1):2–14. doi: 10.1002/pad.584. 11 Kamya C, Shearer J, Asiimwe G, et al. Evaluating Global Health Partnerships: A Case Study of a Gavi HPV Vaccine Application Process in Uganda. Int J Health Policy Manag. 2016;6(6):327–338. Published 2016 Oct 26. doi:10.15171/ijhpm.2016.137

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Partnerships can also be referred to as inter-organisational networks which can be formal (mandated) arrangements or informal (emergent) networks12. Public-Private Partnerships (PPPs) are a specific model of partnerships that governments enter into that are often studied in the literature. PPP for digital health can be convened for different purposes: service delivery, health workforce education, outbreak response etc. Grimsey and Lewis define PPPs as arrangements whereby private parties participate in, or provide support for, the provision of infrastructure, and a PPP project results in a contract for a private entity to deliver public infrastructure-based services13. In PPPs , the public sector often takes the lead, selecting and auditing potential industry partners in line with public health goals. There are three thematic types of PPP described in the literature 14:

o Philanthropic PPP which are characterized by charitable donations of digital technologies or infrastructure

o Transactional PPP which requires a higher level of interaction through shared principles and goals

o Transformational PPP which is the highest level of engagement, involving multiple partners, large-scale programs, and social change

Public Private Engagement (PPE) differs from PPP in that the private sector, rather than the public sector, takes the leading role in bringing together multiple entities—families, schools, communities, policymakers, the media, and nongovernmental organizations, among others—to address health-related issues. One example is the United for Healthier Kids (U4HK) program, now launched in 11 countries by Nestlé which uses social media, mass media, and integrated social digital marketing to reach parents and caregivers directly to provide evidence-based nutrition education14.

Multi-stakeholder Dialogues (MSD) are structured, interactive dialogues that allow stakeholders to better identify challenges and align priorities and action points to assure accountability for resources11. One example in the literature comes from Bangladesh, where government and partners convened an MSD in March 2015. The aim was to increase stakeholder engagement in policymaking and implementation of a national ICT, electronic or mobile health (eHealth or

12 Janice K. Popp, H. Brinton Milward, Gail MacKean, Ann Casebeer, Ronald Lindstrom, Inter-Organizational Networks: A Review of the Literature to Inform Practice, (Washington, DC: IBM Center for The Business of Government, 2014 13 Grimsey D, Lewis MK. 2007. Public Private Partnerships: The Worldwide Revolution in Infrastructure Provision and Project Finance. Edward Elgar Publishing Limited: Northampton, MA. 14 Adam Drewnowski, Benjamin Caballero, Jai K Das, Jeff French, Andrew M Prentice, Lisa R Fries, Tessa M van Koperen, Petra Klassen-Wigger, Barbara J Rolls, Novel public–private partnerships to address the double burden of malnutrition, Nutrition Reviews, Volume 76, Issue 11, November 2018, Pages 805–821, https://doi.org/10.1093/nutrit/nuy035

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mHealth) strategy, which seeks to incorporate ICTs into the national health system, aligning it with the Digital Bangladesh Vision 202115. This white paper seeks to map facilitators and barriers to effective partnerships in digital health and highlight case studies of different models of partnerships that have been effectively scaled for public health. There is a diverse body of literature on conceptualization of partnerships in public policy, as highlighted above. However, there is little literature that studies how to design or evaluate effective partnerships in the digital health sector. There is also a lack of evidence synthesis on what works in different models of partnerships specifically for digital health. For example, are there unique considerations for digital health partnerships that may not exist for other kinds of partnerships for health?

Audience

The intended audience is all stakeholders in the health ecosystem including government, private sector, philanthropy and the public.

Summary of Findings

This study

1) Highlights factors that facilitate or create barriers for effective partnerships as evidenced in the literature and are put into context through excerpts from expert interviews

2) Provides a qualitative analysis of selected examples of successful case models of partnerships in the digital health space in Asia

3) Proposes a roadmap for future national digital health strategies that can lay strong foundations conducive to effective partnerships.

15 Ashraf et al Health Research Policy and Systemsvolume 13, Article number: 74 (2015)

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Methodology

The aim was to map the available evidence on important factors that contribute to or hinder effective partnerships/collaborations in digital health. For this three approaches were chosen, a scoping review, a qualitative research approach and the identification of relevant existing cases studies. Scoping reviews and interviews can be conducted to examine and clarify broad areas to identify gaps in the evidence, clarify key concepts, and report on all the types of evidence that address and inform practice in a topic area16. Cases studies can add additional evidnce on successful projects. . A. Scoping Study The scoping study consisted of a scoping review of the literature. This topic has not been addressed in previous scoping reviews as far as we are aware. Traditional systematic reviews focus on a precise question, typically on effectiveness of an intervention of interest, based on randomized clinical control trials or qualitative studies, but usually not both at the same time. For emerging topics, such as partnerships in digital health, a randomized controlled trial may not be the best method to study the phenomenon. Randomised trials are the gold standard for demonstrating effectiveness of interventions but do not elucidate why an intervention worked or did not work or in what circumstances the outcome may have been different. This scoping review sought to establish a baseline understanding of partnerships in digital health and answer the following questions:

• How are partnerships or collaborations in digital health discussed in the literature?

• What are the factors that facilitate or hinder effective partnerships for digital health?

• How can common challenges be overcome? The review was conducted according to the methodology proposed by Arksey and O’Malley’s framework for scoping reviews17 and in accordance with the Preferred

16 Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017. Available from https://reviewersmanual.joannabriggs.org/ 17 Hilary Arksey & Lisa O'Malley (2005) Scoping studies: towards a methodological framework, International Journal of Social Research Methodology, 8:1, 19-32, DOI: 10.1080/1364557032000119616

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Reporting Items for Systematic Review and Meta-Analysis guidelines for scoping reviews (PRISM-ScR)18. Search Strategy A scoping review was conducted on PubMed, Scopus, and ScienceDirect to find relevant publications on digital health partnerships. To access other relevant publications on digital health, innovation and digital ecosystems, a manual search was conducted using the Google search engine.

Search terms used :

"digital health" OR "telehealth" OR "telemedicine" OR "eHealth" OR "mHealth” AND "partnership" OR "collaboration" OR "multisectoral" OR "cross sectoral" OR "multistakeholder" OR "cooperation"

Inclusion and Exclusion Criteria Inclusion criteria were studies published in English of all types, including editorials and opinions that evaluated or discussed digital health partnerships. We excluded studies in languages other than English and papers on generic health partnerships in areas not related to digital health. Abstracts and selected full text were reviewed by 2 independent screeners. The search period focused on the last 5 years from 2014 – 2019. B. Interviews of experts For the qualitative research approach, interviews were conducted with several experts from across different sectors. Interview themes A topic guide for the interviews was to developed to ensure semi-structured interviews and the abilty to identify themes. The guide is provided in the Annex. Expert Interviews Key informant interviews were conducted with digital health experts to contextualise the insights from the literature review to the Asian Pacific region. The goal was to hear from a diverse stakeholder group. In total, 10 interviews were conducated with professionals in senior positions including government officials, start-up employees, large company employees, academics and entrepreneurs.

18 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. [Epub ahead of print 4 September 2018]169:467–473. doi: 10.7326/M18-0850

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C. Case studies Case studies were extracted from the literature or from other sources such as presentation at the NIHA Digital Forum 2018 and word of mouth. Case studies describe the partnerships and each partnership is evaluated using a partnership evaluation framework. Insights from the review, case studies and the interviews were synthesised using thematic analysis. A narrative summary of the findings and recommendations are in the next section.

Findings

Overall, 29 studies were found that met our inclusion criteria (see Annex for full list of paper references). We performed thematic analysis to synthesise the data with respect to our three main research questions.

1. How are partnerships or collaborations in digital health discussed in the literature?

2. What are facilitators of successful partnerships in digital health? 3. What are barriers to successful partnerships in digital health?

All studies supported the view that partnerships are a positive for digital health and that they should be encouraged. The partnerships discussed in the literature could be broadly categorized by the following criteria : structure, participants, purposes and higher order characteristics. Table 1. Classification of Partnerships in Digital Health

Classification criteria Examples Notes

Structure Formal (mandated) Informal (emergent)

Participants Public-Private Partnerships (PPPs) Academic - Industry Public - NGO

Purposes Multi-stakeholder dialogue Research consortium

PPPs can be further classified by purpose according to Brinkerhoff 19

• Policy PPP

19 Brinkerhoff DW, Brinkerhoff JM. Public–private partnerships: perspectives on purposes, publicness, and good governance. Public Adm Dev. 2011;31(1):2–14. doi: 10.1002/pad.584.

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Patient/Community engagement Telemedicine service delivery

• Service delivery PPP

• Infrastructure PPP

• Capacity building PPP

• Economic development PPP

Higher order characteristics

Philanthropic Transactional Transformational

The majority of digital health partnerships discussed in the literature were mandated (formal) collaborations to provide various telemedicine services. The partnership was usually discussed as part of an evaluation of the telehealth intervention. The majority of studies included in this paper were based on partnerships in developed countries in Europe and North America; those that did include studies of LMIC-based partnerships were mostly in Africa. There is a sparsity of literature studying digital health partnerships in Asia. It was encouraging to find examples of digital health partnerships that were created specifically to address health inequities. These studies were mostly in the United States and focused on digital interventions to increase access, quality and affordability of care to vulnerable populations. Many of the partnerships discussed had a community/patient participatory model. Results from the literature review and the key informant interviews were synthesized to describe the factors that facilitate and hinder effective partnerships in digital health.

Facilitators of Effective Partnerships for Digital Health Trust & aligned values These emerged as the most cited factors for digital health partnership success in the key informant interviews although it was not mentioned as frequently in the literature. Although many interviewees acknowledged that sometimes the motives of industry are profit-driven compared to the motives of health officials, experts felt that over time many view industry as a partner and with less suspicion than in the past. The Sustainable Development Goals (SDGs) have also created a shared agenda between the private and public sectors. A few interviewees did feel that companies new to healthcare may not always appreciate how central clinical governance and risk management is to the running of healthcare organisations.

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Many digital health firms employ physicians but not all physicians have had training in clinical governance and patient safety management at an organizational level. Enterprise risk management in healthcare settings is intrinsically linked to the quality and patient safety culture of an organization. The stronger the risk culture performance the higher the performance in business and clinical outcomes.

We see [industry] as a partner and we need to build trust but we must also

have clarity on our non-negotiables. Patient safety is non-negotiable. -Interviewed government official

Engender ownership among all potential partners It is important to involve all possible stakeholders when planning to scale digital health and to identify what will create value for each stakeholder. Having ownership improves the experience of the collaboration for all involved. The most successful partnerships are those that involved the eventual end-users of the digital technology or key implementation partners such as faith-based and other non-governmental organisations from the outset. The end users could be patients or frontline healthcare professionals providing patient care. Those partnerships that excluded the end-user at the design stage and then tried to obtain their buy-in later faced poor adoption rates even when the technology had evidence of being effective in other contexts. The literature and interviews revealed cases where donor-driven digital health initiatives failed to build the local capacity of partners making projects unsustainable when the donors exited. Similarly, in partnerships with industry, government partners may resent the feeling of reliance, especially where industry have technological expertise that is not transferred to the government agency or industry own the intellectual property of products designed from public data. A genuine sense of ownership should also be fostered among private sector partners. The literature from several global workshops and regional working groups revealed that international donor-supported digital health initiatives tended to focus on public sector and some interviewees felt that partners must support digital health developments in both the public and private sectors to meet the public health needs. In some instances, private sector partners feel they are not engaged in a meaningful way besides being a source of funds. A positive example from the literature, highlighted how Tableau, a technology company was approached to join a consortium that was seeking to employ digital tools to help eliminate malaria in Vietnam and Zambia. Tableau felt the convening organisation approached them in a way that gave them a sense of ownership of the project and meaningful engagement as captured in the quote from the Tableau representative recorded in

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the event proceedings : “What [the partnership] wanted from [our company] was actual engagement and partnership to realise this objective. So we are not engaged just as a donor or a vendor, but as a partner in helping solve problems on the ground.20” Champions for Partnerships Many interviewees highlighted the key role of champions in the public or private sector who were able to make digital health partnerships a reality and sustain them over the long term. Partnership negotiations that may have been stalling in a previous national or organizational administration may find new energy and new champions when there is a change of leadership. Many interviewees identified change in government, healthcare organization leadership and CEO changes as important opportunity windows that provided opportunities for innovative partnerships to advance faster.

Strong Governance and Regulatory Frameworks Having a strong governance framework including national digital health strategies that are coordinated with the ICT strategy, standards for architecture, interoperability, adaptive regulatory frameworks, cybersecurity provisions and ethical principles provides shared goals and vision among prospective partners. Governance refers to the structures, processes, standards, and decision-making authorities that support, regulate and monitor the use of digital health technologies, operational tactics, and data sharing21. Typical governance components include steering committees for strategic decision-making, technical working groups (TWGs) to provide expert advice in key domain areas, and program management units to execute and implement approved strategies and decisions. The WHO-International Telecommunication Union (ITU) National e-Health Strategy Toolkit (Figure 2) was referenced by some interviewees. This was one of the first global guidelines to advise governments, their ministries and stakeholders with a solid foundation and method for the development and implementation of a national eHealth vision, action plan and monitoring framework22.

20 National Academies of Sciences, Engineering, and Medicine. 2018. Using technology to advance global health: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/24882. 21 22 World Health Organization. (2012). National eHealth Strategy Toolkit https://www.itu-ilibrary.org/science-and-technology/national-ehealth-strategy-toolkit_pub/8069793a-en

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Figure 2. Pillars of the WHO/ITU eHealth Strategy Toolkit

Source : Source: World Health Organization. (2012). National eHealth Strategy Toolkit. Regulations Regulation can be a catalyst or hindrance for innovation. A lack of the appropriate regulation for digital health can deter digital health companies from investing in that country, as they may deem it too risky23. As digital health technologies evolve, regulators need to adapt their approaches to be more agile, collaborative and less rigid and overly prescriptive. Although governments understand that policies and regulations encourage the digital health ecosystem there are some barriers to creating explicit regulations. Firstly, there is no specific guidance from respected global bodies such as the WHO on how countries should be regulating digital health technologies or services. Many countries have taken a risk-based approach choosing to regulate high-risk products used to diagnose or treat diseases. These digital health technologies are regulated as medical devices using the traditional regulation approach for those products. However, this class of medical devices (software as medical device) has a much more rapid cycle of updates than traditional medical devices so a more responsive and anticipatory model of regulation is required. Agencies such as the United States Food and Drug Administration (FDA) have issued guidance on how they approach such technologies as a regulatory agency that other countries may choose to reference24. Digital technology has changed the way that health services are delivered which will require a shift in how health services and professionals are regulated. Most

23 National Academies of Sciences, Engineering, and Medicine. 2018. Using Technology to Advance Global Health: Proceedings of a Workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/24882.

24 U.S Food and Drug Administration https://www.fda.gov/medical-devices/digital-

health/software-medical-device-samd

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licensing of health services in Asia is facility based and licenses to provide services are categorised by facility type, e.g. clinic, hospital, nursing home. However, telemedicine services are provided through ICT that does not need any physical facility. Singapore is one country in the region that will be shifting to a service-based licensing regime, moving away from a facility based approach. This will also provide greater flexibility to institutions wishing to provide a variety of services. The test cases of countries with regulations for digital health in place are mostly in high income countries and some interviewees working in LMICs felt these examples are not as applicable in their context. There is a gap in knowledge translation on the ground from the international guidance. Many interviewees from government agencies mentioned that they are sharing best practices among government partners in the region. For example, the regulatory sandbox for telemedicine in Singapore is being studied by others in the region. Striking a balance between appropriate regulation for public safety and allowing innovation is complex and difficult.

Within government, digital policy is moving at a fast pace but the

regulatory framework is lagging behind.

-Interviewed government official

The most commonly cited barriers to effective partnerships are described below :

Barriers to Effective Partnerships for Digital Health

Asymmetry in technical expertise among partners Knowledge asymmetry is more acute in digital health than in other health partnerships creating an unequal relationship. Generally, governments tend to have less in-house expertise in digital health technologies and thus rely on the technical knowledge from industry partners or donors. At the same time, technology partners lack the clinical expertise of healthcare professionals. The digital literacy among healthcare professionals is varied. Among older clinicians, some do not understand the impact of technology or its potential. Many feel there is a need to improve training of physicians in digital skills. Younger clinicians who are already digital natives may face less of a barrier. Many ministries are advocating for change in health professions’ curriculums to incorporate digital skills for the 21st century. There is also an acute shortage of cybersecurity specialists, even within government IT departments. This is of concern given the high profile cyber-attacks on health systems across the world, most recently in Singapore, which was a wakeup call for many regional governments on the risks. In 2018, the

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personal data of 1.5 million patients of SingHealth (the largest public healthcare cluster in Singapore) were stolen in a cyber-attack by an organised hacker group25.

People must realise that if they don’t embrace technology, they will be

extinct like the dinosaur.

-Interviewed government official

.

Lack of evidence of effectiveness of digital health technologies Lack of effectiveness studies for digital health interventions is common. Most national regulatory agencies only require clinical trials (or other sufficient evidence) for digital technologies that are used to diagnose or treat disease which fall under the definition of medical devices. Conducting effectiveness studies is expensive so companies are not likely to do large scale studies or trials unless they are required. However, this lack of evidence is concerning to governments and healthcare organisations who are wary to enter into risky partnerships for unproven technologies. Compared to pharmaceuticals, digital health innovations do not often conduct randomized controlled trials as there are limited funds available to start-ups to conduct clinical trials. Also, there is a chicken and egg situation where it is difficult to conduct such trials without access to patients in healthcare systems, and it is difficult to grant access to patients without evidence of efficacy and safety. Some healthcare institutions have developed internal governance procedures for selection of technologies to test in their patient populations with necessary oversight. Not all health systems have the resources or organisational structures to do this effectively and many risk-averse institutions would shy away from partnering with external companies to test-bed innovations.

Industry does not understand that in health, everything requires an

evidence base. Industry is in a rush to bring technology to market. They are now starting to understand the importance of clinical trials.

-Interviewed government official

25 Tham, I. Personal info of 1.5m SingHealth patients, including PM Lee, stolen in Singapore's worst

cyber-attack, The Straits Times, July 20 2018 https://www.straitstimes.com/singapore/personal-info-of-

15m-singhealth-patients-including-pm-lee-stolen-in-singapores-most

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Varied tolerance for failure The concept of “failing fast” is common in technology circles. This way of thinking encourages risk taking to drive innovation. Healthcare, in contrast, tends to be much more risk-averse because of potential of greater risk to health secondary to adverse events. As non-traditional stakeholders from other sectors such as technology enter into partnerships with health institutions, the different organisational and disciplinary cultures may produce tensions. The combined effect of knowledge asymmetry, lack of evidence and varied risk appetites culminates in either absent or overly restrictive regulatory policies towards data sharing and digital technologies. Another driver for risk aversion is that the risk of losing one’s job or government losing political support is very real if highly publicized and expensive digital projects fail or there is an adverse event or cybersecurity breach.

Lack of effective and sustainable funding mechanisms for digital health partnerships. Digital health needs significant capital expenditure to establish the ICT infrastructure for digital health applications to be used. Hence, the return on investment (ROI) is not immediate and may only occur several years after the initial investment. This requires a long term view on financing where most health ministries operate on short, fluctuating budget cycles. We noted from most interviewees that almost none of their countries currently cover digital health services/products under their government universal health coverage benefit packages. Patients are currently paying out of pocket for such services in most countries in Asia. This is in contrast to the United States where there is increased recognition of digital health solutions such as telehealth, with 40 states having adopted policies to expand telehealth coverage and reimbursement26 . Some digital health companies have inked deals with private insurance companies to reimburse their products/services. Many private insurers work together with companies to manage the health of their employee populations. Providing coverage for digital health solutions such as telemedicine help insurers collect better data on populations to target with preventive health services, telemedicine also helps to reduce costs and increase convenience for users thereby attracting a larger market share. This challenge is not limited to government financing. Similar short-term views of financing are seen in investment by venture capitalists as well as international aid grant cycles, according to stakeholders we interviewed. The majrorty interviewed

26 American Telemedicine Association, 2019 State of the States Report

https://www.americantelemed.org/

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mentioned that outside of China and India there was sluggish Series A funding available to start-ups due to small markets in some countries. Others proposed linking start-ups in small markets with principal investigators (PI) in a larger market to conduct efficacy trials and improve their chances of entering that market. Even in philanthropic funding, the process is often difficult to navigate and not transparent. Many applicants to international aid grants are in the aid organisations networks and so know in advance of upcoming grant calls, giving them a lead time to prepare the comprehensive grant proposals. Those outside the network have to scramble in the short time frame to apply for funding while also juggling running the start-up and raising investment capital. Complex and unpredictable funding streams makes it difficult for small to medium sized digital health companies to participate in digital health partnerships where they could provide the technical know-how but require significant funding support from larger companies or international donor agencies. Contract negotiations with healthcare institutions also create a barrier to partnerships with the private sector, especially smaller start-ups. Legal teams in healthcare institutions often aggressively push for contracts with companies that give the hospital or healthcare system some financial profit. This may be in the form of partial ownership in stock of the company or sharing of intellectual property rights. Sometimes, start-ups may feel the proposed terms are not advantageous to them. At the same time, in negotiations with the private sector public sector hospitals may feel taken advantage of at times when partners retain all rights to digital health technologies developed in collaboration with the public sector or using the institutions health data.

Lack of effective platforms for stakeholder engagement. A majority of partnerships occurred serendipitously or through word-of-mouth network referrals. Many government and non-government agencies do not have an explicit contact point known to outsiders, e.g. a partnership or innovation office that potential partners can approach with ideas. There are very few formal and transparent channels through which potential partners can engage. Even when such innovation offices or agencies were set up the majority of the interviewees did not find them very useful. For example, it was not clear if relevant key stakeholders such as patients and clinicians were even aware of these offices’ existence let alone whether they were active, resulting in their being bypassed by those in the private sector wishing to engage clinicians. Some felt that a patient or clinician-led hub, and especially those around specific disease areas would create more impactful engagement.

People know individuals rather than having a dedicated department for

external partnership engagements

-Interviewed government official

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Innovation is not a building. There are so many of these [innovation hubs] set up but what we as a start-up need is access to the doctors. If the [hub]

does not provide these introductions and promote meaningful connections between us and clinicians it will not have much impact

-Interviewed start-up founder

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Case Studies: Models of Digital Health Partnerships in Asia Pacific

Case Study 1 :

Singapore Ministry of Health - Regulatory Sandbox for Telemedicine

Partners involved : Ministry of Health, several telemedicine providers In Singapore, care across the continuum is delivered via a mix of public and private channels. Healthcare is currently regulated using a premises-based licensing system under the Private Hospitals and Medical Clinics Act (PHMCA). However, this way of licensing is becoming outdated as the health context is changing to respond to an ageing population, rise in chronic diseases, advancing health technologies and increasing healthcare costs. As such, new models of care including telemedicine do not operate from any particular premises and the Ministry is planning to shift to a services-based licensing regime in the near future. There is a growing trend for regulators to use regulatory sandboxes in which they partner with private companies and entrepreneurs. A regulatory sandbox is a framework set up by a regulator to allow small scale, live testing of innovations by private firms in a controlled environment (operating under a special exemption, allowance, or other limited, time-bound exception) under the regulator’s supervision27 . The sandbox regime was first launched in the UK in 2015 by financial regulators and since then, the approach has been quickly adopted around the world and across sectors. Singapore was the second economy in the world to propose a financial regulatory sandbox after the UK and has been an early pioneer of using this approach in healthcare. The Licensing, Experimentation & Adaptation Programme (LEAP) is a regulatory sandbox for telemedicine created by Singapore’s Ministry of Health. Why a Telemedicine Sandbox? Current State: High demand for care modalities that are more accessible to patients

• Several telemedicine providers have emerged to offer video consults with doctors over the last few years

• Doctors providing telemedicine are regulated but the service itself is unregulated as current legislation is based on premises-licensing

27 Chen, Christopher C., Regulatory Sandboxes in the UK and Singapore: A Preliminary Survey (September 6, 2019). Available at SSRN: https://ssrn.com/abstract=3448901 or http://dx.doi.org/10.2139/ssrn.3448901

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Risks identified:

• Inconsistent training and audit of health professionals which may lead to unsafe care

• Inappropriate use of telemedicine by public e.g. for emergencies

• Medication management issues which may lead to care issues

• Inadequate data governance strategies which may lead to data breaches Value proposition for sandboxing

• Better understand the risks

• Explore where and how the care model will be used and where it is growing

• Define safe growth parameters for providers

• Test regulations for burden and efficacy

Limitations of Regulatory Sandbox Approach

• Firms not included in sandbox may argue that it provides unfair advantage to some companies over others

• Not clear how the regulatory framework is defined after the sandbox

• More evidence needed of the impact of sandboxes on innovation and in protecting patients relative to other approaches

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Case 2 : Electronic Drug Safety System (eDSS) - Philippines’ first integrated national pharmaceutical information system

Partners : Start-up mClinica and the Philippines Food & Drug Administration (FDA) In many Asian countries, mom-and-pop style pharmacies are often the first place where patients seek treatment when they are ill. While these community pharmacists are often the frontline of the health system in Asia, they are an often overlooked and underserved stakeholder. Further, pharmacists remain an underutilised resource to promote public health. In the Philippines, although pharmacists are required by FDA regulations to record every prescription they fill in a logbook, in reality, due to lack of time many of the prescriptions are not recorded. FDA inspectors have the right to audit pharmacists’ logbooks but are often too understaffed and insufficiently resourced to be able to inspect more than two premises a day while also performing their other regulatory duties. mClinica has developed eDSS software that allows pharmacists to digitize records of every prescription they fill by simply using an app on their mobile phones. Using artificial intelligence, digitized prescriptions are sent to a cloud-based database, enabling public health insights in real time. Overall, nearly 300 million prescriptions will be digitized every year. As a social enterprise, mClinica has donated the use of the app to the Philippines FDA which was an important factor in advancing the partnership. After a successful pilot in Manila, Philippines adopted a regulation requiring all pharmacists to use the eDSS system which should be rolled out nationally by 2020. Why eDSS? Current situation

• Pharmacists logs are all pen and paper, and recording takes time away from primary work of counselling

• FDA inspectors unable to inspect all physical logbooks due to lack of manpower

• Important information about the health system not captured Gaps identified

• Missed opportunity for public health surveillance e.g. more prescriptions could point to outbreak, can track adherence to medications

• Lack of data on how many people suffer from diseases such as diabetes, tuberculosis, and malaria each year and how they are treated in community settings

• Time of the already few FDA inspectors is not optimised Future State

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• Information collected from over 23 million digitised prescriptions a month can be used to understand disease trends, respond to crises, and even predict outbreaks

• Potential to identify counterfeit medicines in the market

• Overall, nearly 300 million prescriptions will be digitized every year, mClinica is helping the Philippines create its first integrated national health information system

Limitations

• No randomised clinical trials done to demonstrate effectiveness although survey of pilot users (both pharmacists and regulators) was overwhelmingly positive

• Always present risk for cybersecurity breaches though risk management plans are in place

Value proposition

• By connecting the region’s pharmacists and enabling them to share information, the Dept. of Health could improve the care they provide

• Platform has been adapted to provide continuing education to pharmacists in other countries using an app called SwipeRx.

• SwipeRx provides a social media-like interface where pharmacists can interact with other professionals and access educational resources and important announcements from the MOH or WHO in their own languages

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Case 3: Cross-sectoral partnership of Grameenphone Tonic in Bangladesh

Partners involved: Telenor Health (a subsidiary of Norwegian telecom company Telenor) and multiple healthcare providers and hospitals Bangladesh is the world’s 8th most populous country with 168 million people, yet there are just 0.4 doctors per 1,000 people and the World Health Organization estimates that 60 percent of national healthcare spend is not covered by insurance. Health insurance of any kind is in huge demand in many low income countries, including Bangladesh, where universal health coverage is not available. Although insurers wish to provide options to the poorest, they are not able to provide it in a sustainable way. One successful test case of micro-insurance models has been achieved, not by a health insurance company, by a mobile operator. Telenor operates as Grameenphone in Bangladesh and is the country’s largest mobile operator. Tonic was created to provide Grameenphone mobile users with affordable, localised health information on an array of health-related topics as well as access to a primary care physician 24/7 with up to 40% discounts as well as cash back for any hospitalisation more than 3 days. Access to this Tonic basic health package is free to Grameenphone subscribers but the mobile firm has added premium packages that have more services but are still at an affordable price point for many Bangladeshi. One of the major incentives for Telenor to enter into the digital health space is to increase loyalty among its subscribers. Since introduction of mHealth services Telenor has been able to drive more traffic to its network and build customer loyalty, which in turn has had an impact on its market share in Bangladesh. This is one of the first digital health products delivered at such a scale by private sector specifically for an emerging market. Tonic Health Has Four Components :

Tonic Wellbeing Health and wellness content created by Tonic via SMS and social media

Tonic Daktar Telemedicine service available 24/7

Tonic Discounts Up to 40% discounts on services in 200+ hospitals, pharmacies and diagnostics centres around Bangladesh

Tonic Cash 1000 BDT cash when you’re hospitalised for three days or more. Insurance delivered over mobile

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Why mHealth ? Current State

• 800 million new mobile users in Asia by 2020

• Need for scalable, commercial models to provide health services to the poorest

• Mobile technology and AI enabling virtual primary care solutions. Virtual primary care provided using AI can allow patients to have and voice or chatbot conversation in which the virtual doctor asks a series of questions, its AI can calculate likely causes for the symptoms and make recommendations which may include referral to a human doctor.

Future State

• Everyone with a mobile phone can access accurate information to stay well

• Access to quality virtual primary care when needed

• Make quality healthcare more affordable and accessible through microinsurance to cover greater cost of care and bundled packages

• Distributed care and appointment booking

Limitations

• Patients may delay treatment for emergency situations if they inappropriately seek care on the app instead of the emergency room

• Does not transform an inefficient health system but merely aids patients to navigate it better

Value proposition

• For non-urgent, acute cases provides convenient and affordable care

• No extra cost to mobile subscribers for basic package

• Large firm has more resources to invest in clinical quality management, Telenor had standard protocols for telehealth consultations, training program for providers and custom electronic health record system

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Case 4 : Asia eHealth Information Network (AeHIN) Standards & Interoperability Lab AeHIN was established in 2011 to strengthen peer- to-peer learning and knowledge sharing in the South, East and Southeast Asia regions with significant support from the WHO South-East Asia Region. AeHIN works in four strategic areas:

• Build capacity for e-health, health information systems and civil registration and vital systems

• Increase peer assistance and knowledge exchange through effective networking

• Promote standards and interoperability within and across countries

• Enhance leadership and sustainable governance, monitoring and evaluation

The Standards and Interoperability Lab - Asia (SIL-Asia) is a regional interoperability lab that provides technical and capacity-building support to countries in making their healthcare systems and applications interoperable through foundational digital health frameworks, international standards, and emerging technologies. The lab was established by the Asia eHealth Information Network (AeHIN), with support from the Asian Development Bank (ADB) through the People’s Republic of China Poverty Reduction and Regional Cooperation Fund (PRC Fund) to help countries in Asia address their healthcare interoperability needs.

Standards define the set of requirements (data structure, file format, protocol, procedures, processes, systems, etc) that must be met and agreed upon by all organizations within a health ecosystem to deliver quality health services. Interoperability refers to a state wherein healthcare systems have the capability to talk with each other, exchange data, and use information generated from the exchange. 28 Why Standards and Interoperability? Current State

• Lack of standards and interoperability

• Inability to exchange records between two disparate health information systems

• Patient data cannot flow between care settings Future State

• Seamless health data exchange

• Improved care coordination

• Reduces costs

28 SIL-Asia Webite http://sil-asia.org/

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Recommendations to Stakeholders Digital health holds great promise to improve health care delivery, address non-communicable disease and accelerate universal health coverage. The sector has remained fragmented and stuck in the “pilotitis” stage due to lack of coordination, lack of sustainable funding and lack of strategic plans for digital health at a national level. “Partnership” is a Sustainable Development Goal, indicating global recognition for the partnership approach to development. This scoping study has revealed multiple types of partnerships studies in the literature and we recommend that all variations of partnership attempt to achieve transformation, co-creation and human-centred design. There are very few studies analyzing partnerships in themselves; partnerships are instead often discussed in studies whose main aim is to study effectiveness of digital health technologies or interventions. There is still more we can learn about factors that make successful partnerships work or lead to some failing. A closer examination of failed partnerships may give useful insights on how to improve the structure and processes in future partnerships. More evidence is needed to examine if there are unique characteristics of digital health partnerships compared to other health partnerships. Based on the literature review and interviews, we propose the following key recommendations to stakeholder groups for how they can be more effective partners in the digital health ecosystem. Recommendations to Governments/Regulatory Agencies

• Create a national digital health strategy for the country that is complementary to the overall national ICT strategy

• Encourage cross-ministerial approaches to using digital technologies for health and social services

• Establish explicit points of contacts for potential partners in the private and NGO sector to approach with proposals, and a transparent and fair process for consideration of partnership requests

• Evaluate effectiveness of selected interventions in partnership with academic and industry stakeholders

• Employ principles of reliance to leverage on regulatory approvals by other trusted agencies to expedite entry of effective and safe digital technologies

Recommendations to Digital Health Companies

• Prioritise evidence-based approaches, clinical safety and clinical risk management within your organisation

• Identify potential champions in the health sector (clinical, administration and policy) who may be well placed to advise or link you to other early adopters

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• Take advantage of potential ‘policy windows’ to establish partnerships across sectors e.g. change in administration, endorsement of global high-level political declarations by national leadership at UN/WHO level etc

• Integrate capacity-building such as training and infrastructure development, into any partnerships with public sector, especially in developing countries. This ensures long term impact on the health system beyond a single project

Recommendations to Healthcare Organisations

• Develop an organisational digital health strategy within your institution with a focus on development of data standards and implementing interoperability

• Invest in training of the healthcare workforce in using and understanding emerging digital technologies

• Collaborate with patients to discuss how their health data can be used to develop, test and improve digital health technologies and the potential benefits in terms of convenience, costs and patient experience

Recommendations to Funders/Investors

• Simplify processes for grant proposals and monitoring to allow smaller start-ups more opportunities to participate in digital health projects with health systems

• Enhance transparency of funding processes

• Employ outcome-based financing approaches to encourage investment in early stages

• Take a long-term view of financing with an appreciation that full mpact may take time to manifest

Recommendations to Civil Society/ Patient Groups

• Advocate for patient involvement in formulation of digital health policies at national level as well as within specific healthcare institutions

• Curate and disseminate information on policy developments as well as potential uses of health data

• Collaborate with civil society groups in other countries to share knowledge and potentially explore how to share data across borders

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Fostering a Conducive Environment for Strong Partnerships

In order to implement some of the recommendations highlighted above, all stakeholders must collaborate to create a conducive environment at a system level to foster strong partnerships. The key principles to consider are :

1. Human centred-design

Human centred design is a creative process that starts with the people you are designing for and ends with new solutions that are tailor made to suit their needs29. The most important predictor of successful digital health adoption is co-design with the people who will be the end-users be they patients or healthcare professionals. It is important for governments to ensure that healthcare professionals and the public at large are digitally and health literate to fully engage in the creative process of co-design.

2. Establish strong governance and regulatory frameworks for digital health

Policy makers must prioritise and lead a national digital health strategy. The Broadband Commission working group has proposed three governance structures that countries can employ to design and implement the national health strategy: a health ministry mechanism, government-wide digital agency mechanism and dedicated digital health agency mechanism. In the Asia-Pacific region different countries have taken different approaches and the three main structures can be mixed. Australia has established a dedicated digital health agency while Malaysia and the Philippines have instituted close cooperation between the health ministry and the ICT ministry. Figure 3. Three governance structures for digital health

Whichever approach to governance countries take they must incorporate flexible regulatory frameworks to allow innovation while protecting the safety of patients, enforce standards to enhance interoperability and ensure cybersecurity and

29 IDEO http://www.designkit.org/human-centered-design

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privacy are maintained. Emerging technologies present a host of challenges to traditional regulatory models. The current regulatory approach is not well-suited to support the pace of development of digital technologies. Digital technology that uses software is also challenging to regulate as software can make continuous changes to their product to improve features, improve security etc, which is different from traditional medical devices which update less frequently. AI is another technology that poses unique regulatory challenges as many of the algorithms are a “black box”, meaning that it is not always clear even to the developer how it works. There is also a risk of algorithm automated bias which may disproportionately impact groups that are already discriminated against in society. Researchers have outlined some principles to consider when regulating emerging technologies such as digital health. The main principles are : adaptive regulation, regulatory sandboxes, outcome-based regulation, risk-weighted regulation and collaborative regulation30. Adaptive regulation is a responsive, iterative approach to regulation with a more rapid feedback loop to allow regulators to adapt regulations in response to input from stakeholders and evidence. An adaptive approach uses soft laws mechanisms such as standards and codes based on broad principles that are co-developed with industry and not hard law approaches such a statutes and treaties. As discussed in the case studies, regulatory sandboxes are one approach to balance the pace of technology development with safety by providing a controlled but flexible environment to test the technology and regulations. Outcome-based regulation specifies desired outcomes rather than defining the way they must be achieved. Outcome based regulation gives more leeway for innovators to experiment while focused on the desired positive benefit or avoidance of harm27. Rather than a one size fits all approach to regulation, regulators can also use risk-weighting to expedite approval for low-risk technologies, allowing the regulator to focus more on the high risk products.

30 Deloitte Center for Government Insights analysis, The future of regulation , Deloitte

Insights 2018 https://www2.deloitte.com/content/dam/insights/us/articles/4538_Future-

of-regulation/DI_Future-of-regulation.pdf

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Figure 4. Principles for regulation of emerging technologies

Source: Deloitte Center for Government Insights analysis

3. Sustainable Financing : Pay for Outcomes

Financing models must move beyond access and benefits packages which are not sustainable when considering digital technology that is always changing. Many start-ups in digital health in markets such as the United States are shifting into value-based financing agreements where they are paid for clinical outcomes rather than for volume of services given. This will encourage innovations that reduce costs and incentivize digital health providers to coordinate with other partners to produce the best outcomes for patients.

4. Effective Networking Across Sectors This study found that most partnerships arise from word of mouth referrals and many organisations do not have a central point of contact for potential partners. Healthcare systems should create platforms where private and public sector stakeholders as well as patients can interact in an organic fashion on a regular basis. This would diversify the number of partners who are exposed to one another. Networking can also be digital. Digital platforms exist that aggregate data on various innovative companies that could be a starting point for large companies or public sector agencies searching for a partner for a specific project.

5. Cross-country collaboration Learning from similar countries can spark innovation in approaches to digital health. Sharing best practices and experiences with policy, implementation and evaluation with others may help them avoid the same pitfalls. Countries can also

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pool resources to provide training to IT professionals and healthcare workers in their health systems. WHO has promoted the global digital health agenda and should continue to support knowledge translation of global guidelines at a local level. Figure 5. Fostering Strong Partnerships: A Roadmap

Governance & Regulation

Establish, articulate and implement a National Digital Health Strategy

Adopt more responsive and flexible regulatory models

Establish policy for standards & interoperability

Sustainable Financing

Pay for outcomes not services

Encourage deep tech inbucator ecosystem to aggregate some components

Create some less restrictive grants to allow entry to smaller players and encourage innovation

Effective Networking

Create platforms where relevant stakeholders companies, physicians, patients, academics and others can engage directly on a regular basis

Cross-country collaboration

Regularly share best practices at a regional and global level

Human Centred Design and

Informed End-Users

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Have Your Say!

In the spirit of partnership and collaboration, we invite you to contribute to our

crowdsourcing of recommendations of how we can foster strong partnerships to

scale digital health for public health in Asia-Pacific.

Visit co-digital website at the link below to participate in this co-development of a list of recommendations :

https://app.codigital.com/pr-20b69671ef0b9d4efe0866512c53f153/

How it works : The video at Co-digital home page summarises it here : https://www.codigital.com/

1. Anyone with this link can suggest an idea 2. The ideas are served up to participants for a vote which changes the

ranking of the idea 3. In parallel, any participant can suggest an edit to the idea , suggested

edits are voted on by the group 4. Over time, the suggestions and edits that are voted for move up in rank.

Image

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Acknowledgements This work was carried out with the aid of a grant from the NUS Initiative to Improve Health in Asia (NIHA) coordinated by the Global Asia Institute of the National University of Singapore and supported by the Glaxo Smith KlineEconomic Development Board (Singapore) Trust Fund. NIHA was established in 2010 to progress public health and healthcare delivery in Asia through the three integrated programmes of Leadership Development, Policy Forums and Research. The inaugural NIHA Digital Health Forum (DHF), held on 20 November 2018, brought together key thought leaders from the medical-technology industry, digital health start-up sector, academia and various government agencies to discuss the current digital health landscape in Asia Pacific. The speakers summarised global trends and the impact of digital disruption to health systems and described the new landscape in healthcare with the entry of non-traditional players such as tech companies into the sector. This work develops the idea of partnerships for digital health which was raised during the Forum. The authors would also like to acknowledge the following whose expertise was key to shaping this paper either through direct (comments on draft, interviews) or indirect contributions (such as presentations at the inaugural NIHA Digital Health Forum 2018)

• Prof John Lim, Duke-NUS Centre of Regulatory Excellence

• Mr Michael Gropp, Duke-NUS Centre of Regulatory Excellence

• Prof Eric Finkelstein, Duke-NUS Medical School

• Mr Praveen Raj Kumar, Ministry of Health, Singapore

• Prof Matthew Bellgard, Queensland University of Technology

• Dr Zubin J Daruwalla, PwC South East Asia Consulting

• Mr Tian Dongyue, National Health Commission, People’s Republic of China

• Dr Rohaizat bin Hj Yon, Ministry of Health Malaysia

• Dr Fazilah Shaik Allaudin, Ministry of Health Malaysia

• Ms Susan Bennett, MSD

• Mr Krishanthan Surendran, Klinify

• Ms Beth Ann Lopez, mClinica

• Ms Phoebe Jane Elizaga, mClinica

• Mr Craig DeLarge, WiseWorking, LLC

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Annex Topic Guide for Key Informant Interview

Questions Prompts

History of partnership Can you tell about the history of how this partnership came about?

Facilitators What other factors aligned to make this partnership possible/ successful?

Barriers/Challenges Are there any factors that made this partnership difficult at any point? How did you overcome these challenges?

Advice to Others If you were advising an organization similar to your own who was entering a similar partnership for digital health what would you tell them? Is there anything that you would advise other [governments, companies, NGOs] to change to make such partnerships stronger?

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Sources for Case Studies

Case Sources

Singapore Ministry of Health Regulatory Sandbox Partnership for Telemedicine

NIHA Digital Health Forum 2018 presentation slides Interview with Praveen Kumar, MOH MOH Singapore website

Electronic Drug Safety System (eDSS) Philippines’ first integrated national pharmaceutical information system

mClinica website Interviews with mClinica employees: Beth Lopez, Director of Public Affairs Phoebe Elizaga, Head of Public Sector and Policy (Philippines)

Cross-sectoral partnership of Grameenphone Tonic in Bangladesh

UNEP-PSI webinar series "Making inclusive insurance work" - session 3: Health: Telemedicine, insurance and Universal Health Coverage Telenor Health website : https://telenorhealth.com/

Asia eHealth Information Network (AeHIN) Standards & Interoperability Lab

AeHIN website http://www.aehin.org/ Standards & Operability Lab Asia website http://sil-asia.org/

39

PRISMA Search Flow Chart

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Records identified through database searching

(n = 1278 )

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Additional records identified through other sources

(n = 12 )

Records after duplicates removed (n = 739 )

Records screened (n = 739 )

Records excluded : not relevant, not in English

(n = 694 )

Full-text articles assessed for eligibility

(n = 46 )

Full-text articles excluded, with reasons

(n = 17 )

Studies included in qualitative synthesis

(n = 29 )

40

Selected articles from scoping review of literature

S/N Author Year Title Journal Ref Summary Geography

1 Ashraf S et al 2015

Overview of a multi-stakeholder dialogue around Shared Services for Health: the Digital Health Opportunity in Bangladesh.

Health Res Policy Syst. 2015 Dec 9;13:74 Health Policy Asia

2 Fontil V et al 2016

Adaptation and Feasibility Study of a Digital Health Program to Prevent Diabetes among Low-Income Patients: Results from a Partnership between a Digital Health Company and an Academic Research Team.

J Diabetes Res. 2016;2016:8472391

Academic-Private

United States

3 Miyamoto SW et al 2016

Tracking Health Data Is Not Enough: A Qualitative Exploration of the Role of Healthcare Partnerships and mHealth Technology to Promote Physical Activity and to Sustain Behavior Change.

MIR Mhealth Uhealth. 2016 Jan 20;4(1):e5. Multiple

4 Larsen SB et al 2016

Towards a shared service centre for telemedicine: Telemedicine in Denmark, and a possible way forward.

Health Informatics J. 2016 Dec;22(4):815-827

Telemedicine Service Europe

5 Keynejad RC 2016

Global health partnership for student peer-to-peer psychiatry e-learning: Lessons learned.

Global Health. 2016 Dec 3;12(1):82 Cross-country

41

6 Halje K et al 2016

Towards mHealth Systems for Support of Psychotherapeutic Practice: A Qualitative Study of Researcher-Clinician Collaboration in System Design and Evaluation.

Int J Telemed Appl. 2016;2016:5151793

Academic-Clinical Collaboration Europe

7 Weinehall, L. 2017

Policymakers and mHealth: roles and expectations, with observations from Ethiopia, Ghana and Sweden.

Glob Health Action. 2017 Jun;10(sup3):1337356. Public Health

Africa, Europe

8 Lennon, MR et al 2017

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom

J Med Internet Res. 2017 Feb 16;19(2):e42

Public-private-clinical collaboration digital wellness program explicitly delivered at scale rather than as RCT or individual pilot

United Kingdom

9 Bardosh KL et al 2017

Operationalizing mHealth to improve patient care: a qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya.

Global Health. 2017 Dec 6;13(1):87 mHealth Africa

10 Pape L et al 2017

The KTx360°-study: a multicenter, multisectoral, multimodal, telemedicine-based follow-up care model to improve care and reduce health-care costs after kidney transplantation in children and adults.

BMC Health Serv Res. 2017 Aug 23;17(1):587

Telemedicine Service Europe

42

11 Leath, B.et al 2018

Enhancing Rural Population Health Care Access and Outcomes Through the Telehealth EcoSystem™ Model

Online Journal of Public Health Informatics 10(2):e218,

Telemedicine Service

United States

12 Barrett, M.et al 2018

AIR Louisville: Addressing Asthma With Technology, Crowdsourcing, Cross-Sector Collaboration, And Policy

Health Affairs 37, NO. 4 (2018): 525–534

Telemedicine Service

United States

13 De Rosis et al 2018

Public strategies for improving eHealth integration and long-term sustainability in public health care systems: Findings from an Italian case study

Int J Health Plann Manage. 2018 Jan;33(1):e131-e152. Policy Europe

14 Blauvelt C et al 2018

Scaling up a health and nutrition hotline in Malawi: the benefits of multisectoral collaboration.

BMJ 2018;363:k4590 Telemedicine Africa

15 De Pietro C et al 2018

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks.

Health Policy. 2018 Feb;122(2):69-74

Adoption of national EHR policy to encourage cooperation among HC Europe

16 Meessen B 2018

The Role of Digital Strategies in Financing Health Care for Universal Health Coverage in Low- and Middle-Income Countries.

Glob Health Sci Pract. 2018 Oct 10;6(Suppl 1):S29-S40 Multiple

43

17 Winters N et al 2018

Scoping review assessing the evidence used to support the adoption of mobile health (mHealth) technologies for the education and training of community health workers (CHWs) in low-income and middle-income countries.

BMJ Open. 2018 Jul 30;8(7):e019827. Multiple

18 Purnomo J et al 2018

Using eHealth to engage and retain priority populations in the HIV treatment and care cascade in the Asia-Pacific region: a systematic review of literature.

BMC Infect Dis. 2018 Feb 17;18(1):82

Patient Engagement Asia

19 Lopes EL et al 2018

Telehealth solutions to enable global collaboration in rheumatic heart disease screening.

J Telemed Telecare. 2018 Feb;24(2):101-109 Multiple

20 Zhou L et al 2018

Development and Evaluation of a New Security and Privacy Track in a Health Informatics Graduate Program: Multidisciplinary Collaboration in Education.

JMIR Med Educ. 2018 Dec 21;4(2):e19.

Health Professional Education

United States

21 Konduri N et al 2018

Digital health technologies to support access to medicines and pharmaceutical services in the achievement of sustainable development goals.

Digit Health. 2018 May 3;4:2055207618771407 Donor-LMIC Africa

44

22 Doarn CR et al 2018

Development and Validation of Telemedicine for Disaster Response: The North Atlantic Treaty Organization Multinational System.

Telemed J E Health. 2018 Sep;24(9):657-668 Cross-country Multiple

23 Goodrich DE et al 2018

The Phased Implementation of a National Telehealth Weight Management Program for Veterans: Mixed-Methods Program Evaluation.

JMIR Diabetes. 2018 Oct 9;3(3):e14

National Telemedicine

United States

24 Lutkenhaus,RO et al 2019

Tailoring in the digital era: Stimulating dialogues on health topics in collaboration with social media influencers

Digital Health Volume 5: 1–11

Collaboration among health and social medic influencers to combat vaccine misinformation online Europe

25 Bajpai, S. et al 2019

Health Professions' Digital Education: Review of Learning Theories in Randomized Controlled Trials by the Digital Health Education Collaboration

J Med Internet Res. 2019 Mar 12;21(3):e12912

Education Collaboration Multiple

26 Maia, MR et al 2019

How to develop a sustainable telemedicine service? A Pediatric Telecardiology Service 20 years on - an exploratory study

BMC Health Serv Res. 2019 Sep 23;19(1):681

Telemedicine Service/ Cross-country collaboration Portugal - Africa

Africa, Europe

27 Liu C et al 2019

Academia-industry digital health collaborations: A cross-cultural analysis of barriers and facilitators.

Digit Health. 2019 Sep 26;5:2055207619878627

Academic-Industry Asia, US

45

28 Brewer LC et al 2019

Promoting cardiovascular health and wellness among African-Americans: Community participatory approach to design an innovative mobile-health intervention.

PLoS One. 2019 Aug 20;14(8):e0218724

Community participatory

United States

29

National Academies of Sciences, Engineering, and Medicine. 2018

Using Technology to Advance Global Health: Proceedings of a Workshop

The National Academies Press. https://doi.org/10.17226/24882

Workshop Proceedings

United States