Healthcare challenges in low and middle income countries (LMICs) have been the focus of many digital initiatives that have aimed to improve both access to healthcare and the quality of healthcare delivery. Moving beyond the initial phase of piloting and experimentation, these initiatives are now more clearly focused on the need for effective scaling and integration to provide sustainable benefit to healthcare systems.Based on real-life case studies of scaling digital health in LMICs, five key focus areas have been identified as being critical for success. Firstly, the intrinsic characteristics of the programme or initiative must offer tangible benefits to address an unmet need, with end-user input from the outset. Secondly, all stakeholders must be engaged, trained and motivated to implement a new initiative, and thirdly, the technical profile of the initiative should be driven by simplicity, interoperability and adaptability. The fourth focus area is the policy environment in which the digital healthcare initiative is intended to function, where alignment with broader healthcare policy is essential, as is sustainable funding that will support long-term growth, including private sector funding where appropriate. Finally, the extrinsic ecosystem should be considered, including the presence of the appropriate infrastructure to support the use of digital initiatives at scale.At the global level, collaborative efforts towards a less-siloed approach to scaling and integrating digital health may provide the necessary leadership to enable innovative solutions to reach healthcare workers and patients in LMICs. This review provides insights into best practice for scaling digital health initiatives in LMICs derived from practical experience in real-life case studies, discussing how these may influence the development and implementation of health programmes in the future.

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Innovative techniques, potentially using technology, to improve adherence to antiretroviral therapy (ART), may help patients with HIV who struggle with self-care. This qualitative study compared patient and provider participants’ perspectives on ART adherence and text messaging as a tool to promote adherence. Thirteen providers and 14 HIV-infected patients identified four main themes: 1). facilitators and 2). barriers to using text message reminders as a medium for ART medication reminders; 3). framing of text message reminders; and 4). patient responsibility and autonomy in management of their health and wellness. Ease of use, access, convenience, and confidentiality were cited as benefits of a text message based adherence intervention; while access, cost, difficulty manipulating cellular phones, lack of knowledge/education, and confidentiality were cited as potential barriers. Providers, but not patients, also identified patient apathy and time burden as potential barriers to a text message based adherence reminder system. Patients and providers felt that personalization of messages, attention to timing, and confidentiality of messages were key factors for a successful text message based adherence reminder system. Both providers and patients felt that patient responsibility and autonomy over an individual’s own health care is an important issue in adherence to medical care. The majority of patients and providers felt that a text message based adherence reminder system would be beneficial. While patients and providers had many similar views on factors influencing adherence with ART and the use of text messaging to improve adherence, there were some divergent views between the two groups.

Computer-mediated communication systems can be used to bridge the gap between doctors in underserved regions with local shortages of medical expertise and medical specialists worldwide. To this end, we describe the design of a prototype remote consultation system intended to provide the social, institutional and infrastructural context for sustained, self-organizing growth of a globally-distributed Ghanaian medical community. The design is grounded in an iterative design process that included two rounds of extended design fieldwork throughout Ghana and draws on three key design principles (social networks as a framework on which to build incentives within a self-organizing network; optional and incremental integration with existing referral mechanisms; and a weakly-connected, distributed architecture that allows for a highly interactive, responsive system despite failures in connectivity). We discuss initial experiences from an ongoing trial deployment in southern Ghana.

Rural Internet kiosks in developing regions can cost-effectively provide communication and information services to the poorest sections of society. Yet, a variety of technical and non-technical issues have caused most kiosk deployments to be economically unsustainable. KioskNet addresses the key technical problems underlying kiosk failure by using robust 'mechanical backhaul' for connectivity, and by using low-cost and reliable kiosk controllers to support services delivered from one or more recycled PCs. KioskNet also addresses related issues such as security, user management, and log collection. In this paper, we describe the KioskNet system, outlining its hardware, software, and security architecture. We describe a pilot deployment and how we used lessons from this deployment to redesign our initial prototype.