Digital technologies:

shaping the future of

primary health care
WHO/HIS/SDS/2018.55

© World Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.

Acknowledgements

This document was produced as part of the Technical Series on Primary Health Care on the occasion of the Global
Conference on Primary Health Care under the overall direction of the Global Conference Coordination Team, led
by Ed Kelley (WHO Headquarters), Hans Kluge (WHO Regional Office for Europe) and Vidhya Ganesh (UNICEF).
Overall technical management for the Series was provided by Shannon Barkley (WHO Headquarters, Department
of Service Delivery and Safety).

This paper was produced under the technical direction of Diana Zandi and Adriana Velazquez Berumen, WHO
Headquarters, Geneva.

The principal author was Joan Dzenowagis, Consultant, WHO Headquarters, Geneva.

Valuable comments and suggestions to the first draft were made by WHO collaborating partners and office
staff, in particular Susan Brown (GAVI), Bruce Chater (University of Queensland), Gaurav Garg (GAVI), Jun Gao
(WHO regional office for South East Asia), Amanda Howe (WONCA), Dana Hovig (Gates Foundation), Austin Liu
(Consultant, GAVI), Harris Lygidakis (WONCA), Lizzie Madden (Consultant, WHO Geneva) and Ewen McPhee
(Australian College of Rural and Remote Medicine).

The views expressed in this document do not necessarily represent the opinions of the individuals mentioned here
or their affiliated institutions.
Strengthening primary health care:
a national imperative
Across the world, the pursuit of more equitable, comprehensive and integrated models of health
care was first inspired by the Declaration of Alma-Ata in 1978, which encouraged a focus on
primary health care towards “…the progressive improvement of comprehensive health care
for all, and giving priority to those most in need” (1). Forty years later, countries are coming
together to reaffirm their aspiration and collective imperative to strengthen primary health care
as they reinterpret the goals of Alma-Ata in a contemporary context (2). This brief highlights the
opportunities created by digital technologies in achieving the vision for primary health care.

Digital technologies: a force for change

Information and communication technologies were newly emerging when the Declaration of
Alma-Ata was agreed four decades ago. At the time, the adoption of these technologies in health
services was complex, costly and limited. The commonplace technologies of today such as smart
phones, tablets and laptop computers did not exist. However, by 1990 new technologies – notably,
the Internet – had begun to have a revolutionary impact. As they became more advanced (3), more
assimilated in all sectors and mainstream in society these technologies have shown remarkable value
for health.

From technologies that allow people to manage their health more effectively, to better ways of
diagnosing disease, to monitoring the impact of policies on population health, digital technologies
for health, or digital health, are having a profound effect on how health services are delivered and
how health systems are run. The impressive trend in national policies for digital health1 (more than
120 countries by 2015) (4) reflects the firm commitment to use digital technologies to advance the
Sustainable Development Goals, support universal health coverage and shape the future of primary
health care.

1
T he term digital health is used here as an overarching term to include eHealth and mHealth (e.g. telemedicine, electronic
health records and wearable sensors) as well as developing areas such as the use of advanced computing sciences in the
fields of big data and artificial intelligence, for example. Digital technologies also include some medical devices and assistive
devices.

1
 Shaping the future of
primary health care
Improving the accessibility, affordability and quality
of health care is at the heart of primary health care.
The three pillars of primary health care are primary
care and essential public health functions as the
core of integrated health services, multisectoral
policy and action, and empowered people and
communities (World Health Organization. A vision
for primary health care in the 21st century. 2018).
Numerous examples of digital technologies, outlined
below, attest to their versatility, utility and ubiquity
in supporting these pillars in the context of health
development (5).

High-quality primary care and

essential public health functions
Digital technologies of all kinds have become
essential resources in primary care and their uptake
is growing (6), with the past decade seeing rapid
integration of technology in a range of areas that
support primary care and essential public health
functions. In this context, common uses of digital
technologies include searching medical knowledge
resources, facilitating clinical support, monitoring
quality of care, and mapping and monitoring the
spread of infectious diseases, as well as tracking
supplies of drugs and vaccines.

Integrating clinical support tools and referral systems

into primary health care can help coordinate care
and ensure its continuity across primary, secondary,
acute and aged care services. Electronic health
records capture information about an individual’s
health, medical conditions, medications and key
events, which can be shared for referrals and
timely clinical decision-making. Digital technologies
can help improve the patient journey. They can
prevent duplication of care processes and enhance
communication between providers as well as avoid
unplanned hospitalizations and visits for urgent care.
Ensuring that the general public has access to timely,
expert advice by telephone in health emergencies can
save lives.

2
Redirecting interventions from secondary and tertiary care facilities such as
hospital settings to people’s homes through telemedicine, remote care and
mobile health is already transforming primary care and moving health systems
towards a more people-centred and integrated model of health service
delivery. Services such as home monitoring (e.g. blood pressure, medication
adjustment, and blood and urine testing) are key to this trend. Technologies
that enable patient access to personalized information, appointment booking
and tools to manage their chronic conditions provide further support in home
settings.

Technologies can play an important role in patient safety by identifying risks

and reducing harm in the primary care setting. For example, electronic sensors
enable measurement of vital signs and activity tracking to assist staff in
monitoring patients at risk of falls (7). Ensuring that information on prescribed
medications can be accurately and securely shared through electronic
prescribing reduces the likelihood of preventable adverse drug events (8).
Researchers are capitalizing on the value of big data and the power of artificial
intelligence to support complex clinical decision-making and the identification
and reporting of adverse events (9).

Point-of-care diagnostic testing, such as for diabetes, HIV and malaria,

can perform rapid analysis as a critical guide for treatment (10). Digital
technologies have been instrumental in developing the medical and assistive
devices of this century. For example, 3-D printing is revolutionizing the
manufacture of medical devices, orthotics and prosthetics (11).

At the community level, health facility managers incorporating digital

technologies need the knowledge and resources to ensure that the
technologies they adopt fit their needs and can be supported, managed and
effectively used. Local systems should also be able to share data with national
systems, which requires alignment with a national plan as well as with existing
legislation, regulation and policies for data privacy and protection. The
proposed “scale” of technology implementation needs to be planned at the
outset.

The use of digital technologies to inform, support and build capacity is

an important means to empower the health workforce at the same time
as improving the quality of care in primary health care. The future health
workforce already lives in a connected world and will have ever greater access
to digital technologies in both the public and private sphere. Providing them
with communication devices, knowledge resources, and patient management
and decision-support tools gives them the means to be more effective and
autonomous in their work. Facilitating their education and training through
digital tools such as e/mLearning, knowledge sharing and networks improves
and reinforces their professional skills. Enabling learners in communities to
build knowledge and skills through training modules and online courses
offered by distant institutions in order to join the workforce empowers whole
communities.

3
 Multisectoral policy and action
One fundamental way that digital health supports primary health care is by improving
the ability to gather, analyse, manage and exchange data and information in all areas of
health. Digital technologies are being used to improve health information systems from
the community level to district, national and even global levels. Their use also improves
the timeliness and accuracy of public health data collection and reporting (12) and
facilitates disease monitoring and surveillance. They are central to strengthening public
health action, and support rapid, coordinated response in public health emergencies
where many sectors and actors are involved.

The ministry of health is positioned to align the many stakeholders in digital health
around national goals. Leadership and stakeholder engagement are critical, as is a long-
term view to develop digital health in the context of a country’s economic and health
priorities. Partnering with other sectors, such as the information and communication
technology sector, and stakeholders, such as innovators, can develop the expertise
needed to bring innovation to those most in need. Innovative digital technologies,
such as hand-held ultrasound and pulse oximeters, can provide effective diagnosis at
the primary care level and improve the health and well-being of those in low-resource
settings (13).

4
Empowering people and engaging
communities
An educated, aware and engaged public is a goal of primary health care.
Individuals and families can be encouraged to take an active role in their
health and well-being, for example by connecting to high-quality health
information and patient communities online. Effective use of digital
technologies can also support self-care, provide ways to address health
needs, and enable access to health services even when health expertise is at
a distance. With technology, service users can feed back their experiences
of care with the potential for increased transparency in the policy processes
and assessments of health services.

Digital health provides the tools to reach individuals and the public with
health messages that can be acted on, such as targeted health campaigns
or text reminders via mobile telephones to take medication or attend
clinic visits. Personalized support for health behaviour change is another
growing application of digital health. For example, Be Healthy Be Mobile’s
mCessation programme has successfully helped tobacco users in India to
quit tobacco by motivating and supporting registered participants through
mobile text messages (14).

Improving the digital health literacy of the general public can help to
educate, inform, motivate and empower individuals and families, and
help them navigate and reduce the risks of participating in the online
world. Critical appraisal skills regarding information sources, the reliability
and safety of health products and apps, and awareness of social media
influences (such as anti-vaccine messages) are essential skills to foster in
both children and adults. Further research and health technology assessment
are needed on the benefits, acceptability, unexpected outcomes and risks
of digital technologies to patients and the public. Unfortunately, the digital
divide is still a reality to be tackled in many countries in order to achieve
the goals of primary health care. Too many people do not have access to
affordable digital technologies, with the problem being more acute in low-
and middle-income countries (15).

Looking to the future

While the opportunities that digital health offers are increasingly understood
as essential to a modern health system, there are social, economic and
other barriers that affect a country’s ability to take advantage of them and
ensure equity in their use. Harnessing digital technologies for health requires
cross-sectoral collaboration, commitment and strategic planning (16).
Policy-makers need to build the mechanisms and capacity to identify,
assess, support and oversee the integration of promising – as well as
proven – technologies into primary care and public health. There should be
careful consideration of the country context when introducing innovative
approaches, ensuring the necessary oversight and regulation in order to
realize the benefits and avoid harms.

5
 To make digital health a reality in primary health care, countries must address its key
components. These include: building the physical infrastructure; deploying appropriate
services and applications; developing a capable health workforce; ensuring a sound
legal and regulatory environment; and improving governance, policy, standardization
and interoperability (16). It will also be critical to ensure that cross-border, regional
and international efforts work in harmony and that governments build mechanisms
to collaborate and share lessons learned. Governments are moving away from pilot
projects towards strategic, integrated planning and sustainable financing mechanisms.

While technological development moves quickly, the same is not always true of
public policy, clinical practice and the generation of evidence. Policy-makers must
often decide whether to go forward based on imperfect evidence. Research on and
evaluation of digital health outcomes and impact are therefore essential to support its
safe and ethical implementation, promote accountability and justify the investment of
funds.

As individuals increasingly become agents in their own care, policy frameworks and
the use of digital technologies (such as biometric identification) must protect privacy
and security if trust in digital health is to be maintained. Suitable regulation is also
needed to ensure the quality and safety of software products, devices and applications
that are used not only in primary health care but that may also be directly marketed or
otherwise available to individuals.

6
Developing the digital skills of the health workforce is critical. Health
professional training and education programmes will need to ensure that
the workforce can use digital technologies proficiently in many settings,
whether in the delivery of care, its management and administration, or in
health systems planning and management.

There are many stakeholders in the digital arena: companies, non-profit

organizations, foundations, engineers and innovators, academia, research
and scientific institutes. In addition, nongovernmental organizations,
donors, service providers and government institutions, individuals, families
and communities play key roles, which continue to evolve in the digital
health environment. Many see the potential for growth and acknowledge
the need to work together to make advances relevant, safe, affordable,
transparent and accessible. Those working to develop and promote digital
technologies can be important strategic partners for governments. In that
context, they must also recognize their responsibility to align, deliver, sustain
and demonstrate value beyond the initial excitement of a launching a new
technology or initiative.

Conclusion
Digital technologies have already opened up a wealth of possibilities
for shaping the future of primary health care and ensuring effective
public health action. They have catalysed a host of changes in education,
policy and practice as well as created new patterns of communication,
empowerment and engagement. A recommitment by governments to
the goals of primary health care and its values of inclusiveness and equity
promises more changes to come, with digital technologies central to the
vision and its realization.

7
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