Digital technology can do many things to strengthen health systems. Christoph Benn of the Joep Lange Institute opened this session by arguing that perhaps it can make the most impact in primary health care – an area that has been underappreciated and underinvested for decades. He presented a concept note for an investment case and several illustrative examples, including digitally enabled community health workers in Nepal transforming maternal and child mortality and morbidity; the MomConnect project in South Africa using mobile tools for health promotion, data collection and user feedback on healthcare facilities; and M-TIBA in Kenya providing a safe, secure, low cost platform to connect patients and providers, making systems more efficient, reducing payments and helping people save money and acquire health insurance with near zero transaction costs. On the diagnostic side, connected rapid tests for a range of diseases can be used in remote facilities and connected to cell phones and used for surveillance, or to suggest next steps in treatment and care, empowering community health workers in transformative ways.

Three new coalitions have been established to promote these processes to different target audiences. The Transform Health Coalition caters mainly to civil society and communities, with a focus on engaging young people and women with the possibilities and opportunities of digital health. Its vision is to achieve Universal Health Care (UHC) by harnessing data and digital technology, through a global movement of young people all over the world based on equity, empowerment, inclusion and partnership. Its objectives are to strengthen political will for digital technology in primary health care; to promote a global data governance framework for secure, beneficial use of data; and to increase domestic and international investment in digital-enabled primary health care, bridging the digital divide. The second example is the Digital Connected Care Coalition, aimed mainly at the private sector and dedicated to accelerating transformation of digital healthcare to achieve UHC in low- and middle-income countries. The Coalition invites innovation from companies all over the world, connecting them in a network from which all can benefit. The third coalition is I-DAIR, the International Digital Health and Artificial Intelligence (AI) Research collaborative, and is mainly for scientists. Inspired by the Commission of the UN Secretary General and co-chaired by Jack Ma and Melinda Gates, it seeks new collaborations to promote relevant approaches to digital health and AI, focussing on the needs of the most vulnerable with targeted research. It has a CERN-like global approach to problem-solving, with a hub-and-spoke architecture, a USD1.5billion impact fund for investment, and the objective of convening researchers and entrepreneurs around global health challenges, developing and maintain global public health goods, and promoting data interoperability.

Pradeep Kakkattil of UNAIDS followed up with a story. Not long ago he found himself chatting to a minister with whom he was sharing a panel about how he was approaching 50 and seeking purpose and meaning in life. In response, the minister pointed out that he was lucky to have an opportunity to plan; in his own country, at that age most people have a year or two left. Shocked into a change, Pradeep has been involved in innovation ever since, and particularly the work of the Health Innovation Exchange. One in two people in the world have no access to essential health care – a stat from before the pandemic – but there are so many approaches and technologies already existing that can be transformative. The tools and resources exist to solve the problem; we can digitally enable community health workers and connect them together and predict outbreaks; and yet countries are reluctant to apply these technologies at scale. It is a fascinating phenomenon. The temptation is to conclude that these tools are unavailable in low-income settings, but no. On investigation, health ministers tended to give four reasons. Firstly, nobody bothers to speak to them properly about their particular pain points and challenges. Secondly, everybody is trying to sell countries different things and it can be impossible to know where to invest. Thirdly, the responsibility for many potentially transformative solutions lies outside the health sector (for example, it is hard digitise the health system and establish electronic health records when 50-70% of health of facilities don’t have enough energy and about half are completely off-grid – and when government hierarchies prevent ministers of health speaking to ministers of energy). Finally, there is the predictable issue of funding. Donors often end up investing in pilot after pilot, with vastly insufficient innovation at scale. There is a need for global oversight that describes where the opportunities are, what resources are needed and what the returns will be. It will also be crucially important to engage private investment in building sustainable health care businesses. There is a huge funding shortfall, and it will not be filled by traditional sources.

In response to these issues, the Health Innovation Exchange positions itself as a trusted mutual broker that works with ministries of health identify their issues; with and within the innovation ecosystem to find the best and most relevant solutions; and with the investment sector to bring them to scale.

A period of discussion followed in which a range of ideas were shared on how better to involve people on the ground in decision making, including around investment; how best to join together existing initiatives; and the many possible roles of the private sector, including the private sector in low- and middle-income countries. As ever, failures to scale up emerged as a common issue, with siloed working a principal scapegoat. The multiple coalitions presented by Dr Benn are designed to overcome these issues at an international scale; and the Health Innovation Exchange developed in response to many years of excellent pilots and start-ups developing health initiatives to the point where ministries became overwhelmed. All of this is well-intentioned, but the overall goal is simpler: strategically sound, country-driven, country-based and financed national plans supported by all relevant stakeholders. These coalitions and other such international initiatives provide platforms and frameworks that support this goal.

It will be important that such coalitions are able to integrate effectively into national strategies in this manner. In many contexts, there is still a very long way to go in digitising health, especially for rural communities grappling with issues of network reliability and digital literacy. Manifesting change at community level is a serious challenge. One encouraging recent example is that of the Tanzanian government’s comprehensive, costed plan for digital transformation. Other countries exploring similar initiatives include Ethiopia, Democratic Republic of Congo and Rwanda. More and more countries are developing these plans, involving a range of stakeholders and bottom-up approaches. The shared vision is one where ideas, enthusiasm and strengthened human capacity come together into real, implemented plans. The world has been through an uncoordinated frenzy of creation; a phase of organisation dawns.

Such organisation can also help the private sector realise its own, very important role. Innovations often come from private companies, but if every company just presents separate ideas in different places, there is no progress. Coalitions give companies a platform and a joint voice with which to talk to WHO and other major international and multilateral organisations that provide normative guidance, and thereby, hopefully, to achieve coordinated and well-financed approaches.

As was clear in the previous day’s session, partnerships with faith organizations also have a crucial role to play. The Transform Health Coalition is open to everyone, including faith communities and organisations at all levels.

Investors are important too. Giovanni Magni explained his own frustration with the inability of investors to understand not only the needs of low- and middle-income countries, but also the many and varied opportunities to make profits helping people in these countries, both achieving social and development impact and making money. The current landscape for investment in start-ups developing technology that is simple, effective and cost effective in low-income settings is dominated by US and European companies. More funds should work with local companies in low-resource settings to develop these technologies for maximum impact on the ground—and not only the technologies themselves, but also innovation in other areas, such as distribution and engagement.

As underlined by Manel Djiar (Qiagen) and Hilke Rosskamp (Boehinger Ingelheim), industry stakeholders can – and should – use these networks too. New territories and countries can look complicated from the outside, making new initiatives appear dauntingly difficult to companies. There are too many stakeholders and not enough local presence; unfamiliar partners and distributors may be needed in order to act. The natural response, all too common, is to target a small number of pre-existing, more familiar markets. It is to be hoped coalitions and networks can help companies identify the right stakeholders to target in countries to ease the path to supporting local industry, stakeholders and communities. Ultimately, partnerships are a matter of trust, and any initiative that makes building trust easier is to be welcomed.

Health is a holistic concept, and by necessity involves mental as well as physical health. Innovation developments in the coming years will need to be implemented with sensitivity to the growing importance of mental and psychological health, especially given the widespread trauma inflicted by the pandemic.

In all these things, bridging existing initiatives, coordinating and avoiding duplication will be crucial. More south/south collaboration is needed. Industries that have focussed the majority of their business on developed markets will have to adapt to a need to be present in emerging markets across the world – supported by, and developing, technology originating in the South. The will is there to realise this vision. The coalitions and networks are there. Together we must use these and other ways to develop new partnerships, working much more efficiently than before.

In conclusion to the session, Ahimsa made a commitment to Christoph and Pradeep. The Fund will do all it can to facilitate access to these innovative platforms, both for industry and for the world of trusts and foundations.