Raman Sohal, Onil Bhattacharyya, Will Mitchell, University of Toronto 

Contact: Will Mitchell, william.mitchell@Rotman.Utoronto.Ca 

Introduction

Health systems around the world are increasingly recognizing the benefits of value chain integration (VCI) strategies to foster scalable services (Kim, Farmer, & Porter, 2013; Porter & Teisberg, 2006). VCI strategies involve coordinating the activities of partners that help design, develop, produce, and deliver goods and services to customers (Adner, 2006; Mitchell, 2014). These strategies help global health services that target base of the pyramid clients overcome barriers to growth that arise from the complexity of the broader ecosystem in which healthcare activities are embedded. VCI offers the potential for health service organizations to work with skilled partners for funding, health services delivery, logistics, political support, and other key elements of the healthcare value chain. Yet we are only beginning to understand the nature of VCI in global health, as well as the challenges that organizations face in implementing the strategies.

This qualitative study examines how health services delivery organizations use value chain integration to achieve scale lower and middle income countries. We describe how ten private sector global health organizations operating in Africa, the Americas, and Asia are using VCI strategies, highlighting both successful routes and challenges to achieving sustainable scale. We selected the cases based on their ability to help us refine and develop categories of VCI as an emerging conceptual framework in global health delivery. We identify three main mechanisms for using a VCI strategy to scale up health services delivery: identifying mutual dependency with partners, creating an efficiency core (Wong et al., 2014), and building a strong set of four types of management skills, including financial skill, quality management, supply chain management, and client relationships. The base conclusion is that – despite real challenges – creating value chain integration partnerships with diverse actors can help global health enterprises serve clients effectively.

Table 1 summarizes the ten cases. Four organizations operate in one country while the remaining six operate in two to 42 countries. Six have for-profit legal structures and four are non-profit.We drew on existing literature and then supplemented the data by interviewing leaders of five of the organizations. The published research and interviews provide lessons about how organizations implement VCI strategies.

Table 2 lists nine common value chain steps for health services delivery: 1) financing, 2) infrastructure and set-up, 3) obtaining real-estate, 4) registration and permits, 5) recruitment, 6) supply chain management, 7) identifying clients, 8) marketing and branding, and 9) delivery.

Mechanisms for a VCI Strategy

Identifying mutual dependency with partners

An underlying tenet of VCI strategy is that organizations should not try to do everything themselves, especially activities where other actors in the ecosystem have superior skills and positions (Porter, 1985; Mitchell, 2014). Capron and Mitchell (2013) highlight that strategic challenges lie not only in identifying which resources are needed, but how to obtain resources. The organizations in our sample developed alliances with partners at different stages of their value chains (Table 1). Resource-limited health services organizations that are effective at identifying relevant mutual dependencies can often borrow critical resources from partners in order to pursue expansion goals. Kramer and Pfitzer (2016), for example, note: “The first large-scale program to diagnose and treat HIV/AIDS in South Africa was introduced by the global mining company Anglo American to protect its workforce and reduce absenteeism.” In 2016, Anglo American formed an alliance with UNAIDS to support ProTest HIV, a global initiative that encourages people to be tested for HIV. Research demonstrates that scaling global health delivery requires support from a range of partners, including governments, bilateral and multilateral aid agencies, and the private sector (Bhattacharyya et al., 2010). Examples from our study offer powerful insights.

North Star Alliance

North Star Alliance in Sub-Saharan Africa has used value chain partners predominantly in steps one, three, four, six, and seven of the value chain. North Star’s value chain requires that the organization acquire land, set up clinic infrastructure, maintain medical stock supply in order to provide healthcare delivery to truck drivers and sex workers. As a non-profit health services organization, North Star has developed alliances with different types of actors in order to obtain tangible and intangible resources it needs to deliver healthcare to mobile populations along transport corridors in several African countries. When it launched its operations, North Star received significant public support from the humanitarian, government, and private sectors. The impact of the HIV/AIDS crisis on a productive workforce of truck drivers enabled North Star to leverage support from potential allies such as the United Nations World Food Programme (UNWFP) and partners in the commercial sector such as the global courier company TNT Express. These partnerships allowed North Star to obtain the financial resources needed in the first stage of the value chain to establish a network of 36 Roadside Wellness Centres in ten countries.

Health services organizations that can align goals throughout their partnerships often can expand their resource base. In Kenya, as Figure 1 depicts, North Star Alliance has been able to formulate an alliance, along step three of its value chain, to procure free land for all eight of its clinics from the Kenya National Highway Authority (KENHA). While many entrepreneurs bid for the same land, North Star reached an agreement to set up its clinics along the transport corridor and write-off rent – a significant cost.  KENHA, due to its contracts with investment banks, must provide HIV/AIDS services to its contract employees, who are highway construction workers. A manager from KENHA told us that “Because of our agreements with the investment banks, there is a clause that we have to provide HIV services to our workers. We don’t have the capability to do this on our own. We had a hard time finding an NGO that provides HIV services to immigrant workers on contract along the highway. North Star is the only organization we know of. North Star is helping us.”

Unjani Clinics

Unjani Clinics is a social franchise that has established nurse owned and operated clinics for the underserved in South Africa. Unjani is the corporate social responsibility arm of a pharmaceutical company, Imperial Health Sciences. The Unjani Clinic model contributes to strengthening South Africa’s health system and creating employment under the national Black Economic Empowerment (BEE) program. The BEE Codes of Good Practice compel large companies to spend three percent of their net profit to develop small and medium enterprises with a majority black shareholding – two percent for businesses within their corporate supply chain and one percent to help grow other businesses (Gordon Institute of Business Science, 2016). Mutual dependency between Unjani and this South African government initiative in turn helped Imperial Health Sciences position itself to attract government tenders (step one in the value chain) for its core business operations.

Leveraging shared distribution channels

Leveraging shared distribution channels offers a powerful means of benefiting from mutual dependency. Within the value chain, an important stage is setting up infrastructure to establish clinics (step two). Procuring real estate to set up operations can be costly for social enterprises targeting the base of the pyramid. One means through which organizations in our sample have managed to reduce or write-off set-up costs is by leveraging shared distribution channels.

Lifenet International

Lifenet’s conversion franchise model largely dispenses with staffing and focuses on managing existing providers in the healthcare delivery value chain in Burundi, Uganda, and the Democratic Republic of the Congo. Lifenet originally piloted a model in which nurses would do outreach in the communities to deliver primary care. During the pilot phase, Lifenet realized that existing church-run medical centers not only already provided healthcare to Burundi’s rural poor, but also had significant buy-in and trust from the community. Rather than create a parallel system, Lifenet abandoned the nurse-led model and developed a franchise system to bring existing providers into the Lifenet network. This enabled the providers to increase the value of their primary care delivery to the rural poor. Lifenet’s franchise model includes nurse training, management training, growth financing, and pharmaceutical supply.

VisionSpring

VisionSpring partners even more intensively than Lifenet to supply eyeglasses to partners via an existing distribution system’s existing client base in countries throughout the world. In Bangladesh, VisionSpring has leveraged the national distribution capacity of the Bangladesh Rural Advancement Committee (BRAC). VisionSpring uses BRAC’s existing sales force, which includes approximately 80,000 women who sell baskets of health-related goods such as Band-Aids and Aspirin  (Hassey & Kassalow, 2014). By partnering with BRAC, VisionSpring achieved rapid scale and reduced its own training and administrative costs. In South Africa, VisionSpring partnered with Unjani Clinics (Center for Health Market Innovations, 2013). While Unjani’s patients are able to access primary care services at the clinics, vision screening was problematic as the Unjani network did not want to offer the screening without offering clients the ability to purchase the glasses at the point of care. VisionSpring places orders for eyeglasses for its partners and manages all supply chain logistics (VisionSpring, 2013). VisionSpring has found a sustainable specialized position in healthcare delivery and is coordinating a focused piece of the healthcare delivery value chain through extensive partnerships.

These examples illustrate how social enterprises have been able to leverage resources from a range of partners in order to fulfil their core mission of health services delivery at the base of the pyramid. The ability to draw upon existing infrastructure and distribution channels has enabled these social enterprises to significantly reduce their start-up and ongoing costs and simultaneously expand their reach. As the examples illustrate, value chain integration requires health services organizations to be deliberate in reaching disparate types of partners that are needed along stages of their value chains from financing, setting up a clinic, and health service delivery.

Simply creating and managing partnerships is not enough for a successful VCI strategy. In addition, the lead organizations benefit from enabling strategies in the form of developing an efficiency core (Wong, Zlotkin, Ho, & Perumal, 2014) and gaining strength in four key types of management skills.

Enabling Strategy 1: Developing an Efficiency Core

The global health literature highlights standardization and simplicity as necessary ingredients for scaling interventions (Cooley & Kohl, 2006; Simmons, Fajans, & Ghiron, 2009). The notion of the efficiency core refers to the standardized part of a model that can be replicated with minimal modification to fit local contexts (Wong et al., 2014). Each of our cases has an identifiable efficiency core, as Table 1 summarizes.

• North Star Alliance: North Star has an efficiency core consisting of a blue-box shipping container that provides the office, together with a lean staffing model comprised of five individuals: clinical officer, HIV testing counselor, site coordinator, receptionist, and security guard.
• Unjani Clinics: Unjani has an efficiency core consisting of a shipping container clinic owned and operated by a nurse from in the local community. Unjani trains nurses in entrepreneurship and business management.
• VisionSpring: VisionSpring has an efficiency core consisting of Vision Entrepreneurs who use a “Business-in-a-Bag” approach to operate micro franchises, traveling from village to village to conduct vision camps, check eyesight, and sell glasses through door-to-door sales (Hassey & Kassalow, 2014).
• Riders For Health: Riders’ efficiency core is a fleet management system. The system involves managing health workers’ motorcycles, conducting regular preventive maintenance, and training workers (Business, 2014). Riders developed a replication team that can introduce their system in any country or any project of any size. For example, the team replicated the Riders system in less than two months in Liberia during the Ebola crisis.
• Jacaranda Health: Jacaranda uses a standardized model targeted on maternity care for its chain of clinics in Kenya.

In addition to creating an efficiency core as part of pursuing a VCI strategy, organizations need strong management capabilities in order to create value for hard-to-reach and last mile populations at the base of the pyramid.

Enabling Strategy 2: Four Types of Management Capabilities

Four types of management capabilities support the VCI strategies in our organizations. The first three categories are supply-side factors: developing financing strategies, driving quality, and investing in strong supply chain management. The fourth category emphasizes the demand-side factor of building strong client relationships. Table 3 offers examples.

Supply side: Develop financing strategies

A crucial stage of any value chain is the financing stage, which involves the ability of an organization to fund core operations in a scalable manner (Chandy, Hosono, Kharas, & Linn, 2013). Several of the organizations use fee-for-service models, commonly with consultation fees plus additional fees for medicines and lab services. However, fee-for-service models can face strong challenges. Jacaranda Health, which launched its operations in 2011, runs a fee-for-service model in two maternity clinics in Kenya. The CEO of Jacaranda notes: “Hospitals are high-fixed cost ventures. We still haven’t broken even. We’re almost there and we hope to do so by this December.” Beyond fee-for-service, several organizations use complementary financing models that support free or subsidized services. The following examples focus on the first step of the value chain, where developing a sustainable financing strategy is in integral component of an organization’s value chain.

Penda Health: Fee for service

Penda Health has adopted a fee-for-service model for its chain of primary care clinics in Kenya. Penda’s co-founder notes: “When we first started operations in 2012 it took us years and years to break even. Now if we set up a clinic we can break even in six to eight months.” Penda’s financing strategy involves finding a client base amongst populations that have the ability to pay, such as factory workers and university students.

Penda partners with schools and factories to drive high volumes to their clinics. For example, Penda partnered with the Management University of Africa (MUA) to support a university-sponsored capitated health insurance scheme for students and staff at MUA. The on-campus clinic at MUA caters to 800 students and staff who have employer-sponsored insurance. Penda also partnered with the Masaai Flowers Factory to provide health services to factory workers, using a post-paid model. Under this model, the factory workers do not pay out-of-pocket at the point of service. Instead, Penda invoices Masaai Flowers at the end of each month and the company deducts the healthcare costs from the employees’ pay cheques. Penda is currently expanding its post-paid model to attract other large employers.

Unjani Clinics: Social franchises

In South Africa, Unjani’s fee-based service model enables sustainability and the empowerment of black women through franchised businesses. The ownership model has a built in incentive whereby the professional nurse increases her ownership share annually, based on a franchise agreement with Imperial Health Sciences Limited. The nurse initially pays about US$790 as a commitment fee, which covers the cost of management training in areas such as marketing, standard operating procedures, bookkeeping, record keeping, IT skills, and Unjani systems. When Unjani began in 2010 the nurses were paid a full salary, as Imperial was not convinced the nurses had an appetite for financial risk (Gordon Institute for Health Sciences, 2016). Once the pilot phase was over, however, the model was structured such that as a clinic breaks even, the extra profit becomes the nurse’s salary. Imperial also provides working capital. Each Unjani clinic receives working capital of $900 a month for the first 8 months, then $600 per month for the next 8 months, and finally $300 for the next eight months. The contribution helps the clinic to set up and to build up a client base.

Ziquitza Healthcare Limited: Complementary revenue

Ziquitza Healthcare operates an ambulance service in India. Ziquitza’s business model uses a sliding price scale driven by a patient’s ability to pay, which is determined by the kind of hospital to which patients choose to be taken (public or private). Ziquitiza generates complementary revenue from private hospitals that advertise their services on Ziquitza ambulances (Center for Health Market Innovations, 2016).

Supply side: Drive quality

Driving quality refers to all nine steps of the value chain. As social enterprises expand in size, managers face challenges to maintain quality along each stage. Growth requires robust monitoring to ensure that quality control mechanisms are adhered to by each franchise or clinic.

Penda Health’s eight clinics in Kenya have systematically found ways to compete on quality. Penda has developed a system whereby a mystery patient visits each Penda clinic every week to identify risks that may undermine the delivery of quality care. A clinic receives one demerit score per identified risk – the goal is to achieve under ten demerits per month. Penda’s co-founder told us that “clinics that perform above average are given a bonus.”

In addition, Penda has created a Medical Advisory Board. Physicians who are members of the Medical Advisory Board review nurses’ charts, auditing ten percent of the charts per week. Where there are gaps in care, physicians provide the nurses with advice about clinical quality. Penda’s co-founder reports that where there is clustering of errors in a particular category, the nurses receive refresher training. Penda further surveys its clients to understand whether clients are satisfied with the care they receive at the clinic.           

Supply side: Invest in strong supply chain management

Supply chain management, step six, is a key component of value chain integration. The supply chain is focused on conveying products and services from a beginning point to an end point. Supply chain management involves bulk storage and transportation (Feller, Shunk, & Callarman, 2006).

Healthy Entrepreneurs

Health Entrepreneurs deploys a last-mile distribution model to deliver affordable and reliable health products and services to the poorest families in rural areas. Healthy Entrepreneurs has created its own end-to-end distribution chains. Through a network of trained micro-entrepreneurs who operate pharmacies and health facilities, the organization manages an end-to-end value chain of reliable products and practical health information. In order to prevent stock outs, Healthy Entrepreneurs delivers products directly to the entrepreneurs via local depots (Center for Health Market Innovations, 2016).

Lifenet International

By linking rural partner health centers with local and regional wholesalers that deliver medicines directly to the centers, Lifenet has removed bottlenecks in the medical supply chain. Prior to launching the program, nurses were often purchasing medicines themselves: spending days traveling to cities by public transportation in order to buy whatever was in stock at whatever price and quality available, before making the long return journey to their health centers. By developing supplier relationships with local and regional wholesalers, Lifenet’s health centers avoid stock-outs, manage debt, and are financially viable, ensuring their sustainability.

Demand side: Build strong client relationships

While healthcare organizations face temptations to focus on supply side factors, the last stage of a social enterprises’ value chain is often the delivery of a healthcare service. Research reveals that simply providing a needed health service often is not enough (Wong et al., 2014). Koh, Hedge, & Karamchandani (2014) note that some markets offer “pull” products, which most target customers readily demand, such as microfinance loans to credit-starved households at much lower interest rates than money lenders.

In contrast, health is commonly a “push” product. Consumers “do not readily perceive the need for these [push] products as they are unaware of the problem, solution, or both. Often, even if they are aware of the problem, they are unable to easily try out the new solution to understand its value proposition, leading them to make do with established, inferior solutions” (Koh et al., 2014: 23). For social enterprises providing health services to lower-income populations, addressing the last stage of the value chain, which centers on the demand side, is key to driving scale and viability.

North Star

While North Star establishes its container clinics along the transport corridor, interviews with managers, clinic staff, and clients revealed that despite the proximity of the clinics to the truck-stop parking lots, it was often difficult for drivers to leave their trucks in order to seek care. A truck driver parked at the border of Kenya and Tanzania told us: “If my turn boy [assistant] is not here and I leave, in 15 minutes some of my fuel is taken and cargo stolen.” Another truck driver told us: “We are tracked by GPS by our companies. If I go off one road, we get a call from the company.”

Recognizing the difficulty for truck drivers to access its clinics, North Star developed an outreach strategy. Each week, HIV testing counsellors visit truck drivers during their breaks or while they park overnight at a border crossing. A HIV testing counsellor in Salgaa, Kenya notes: “most of the time we need to do outreach and do HIV tests in the truck drivers’ cabins. Most of them will not come to the clinic.” North Star notes that its clinic teams along the transportation corridors must conduct regular behaviour change and communication sessions in nearby communities in order to meet their target volumes, typically aiming for 25-30 clients per day per clinic.

Operation ASHA

By establishing tuberculosis clinics where there is significant foot traffic by base of the pyramid consumers, Operation ASHA address many of the critical demand side factors that prohibit people from seeking and adhering to TB treatment, such as transportation and time travelling to and from clinics. Patient convenience, community mobilization, and comprehensive counselling form core elements of Operation ASHA’s services (Center for Health Market Innovations, 2016). Providing convenience for customers in accessing TB treatment is a crucial aspect of Operation ASHA’s model given that promoting adherence to TB is often challenging (Makanjuola, Taddese and Booth, 2016).

These two examples highlight the point that, for social enterprises targeting lower-income consumers, it is often necessary to adjust offering to meet patient demand in order to achieve goals of the last stage of the value chain, which focuses on the delivery of a health product or service. The Operation Asha example illustrates how adapting services to the needs and interests of local populations is critical for scaling success. The North Star case emphasizes that targeting different types of mobile populations from truck drivers and sex workers requires understanding local realities and constraints.

Despite the successes, health services organizations also face major issues with VCI strategies. Below we discuss cases from our sample in which organizations confronted scaling challenges.

Pitfalls in Value Chain Integration

Failure to create effective partnerships for key resources can constrain an organization’s expansion goals.

Penda Health

In Kenya, Penda sought to expand its presence in Machakos, near Nairobi. While factories in the area were keen to have Penda offer its services to their employees, the partnerships fell through because Penda could not find an appropriate location for a clinic. Penda told us: “…we thought we had secured the perfect location for partnering with many of the factories in that area, but illegal actions by the landlords there caught us off-guard and, after a protracted struggle, we withdrew from this location.” Penda further noted: “We learned that finding a location, is very, very hard, so you should start with a location and then find the community partners nearby. Or, have the community partner give you space.” This example illustrates how external actors can undermine expansion efforts. Penda secured a partnership to attract a paying clientele, but was unable to realize the gains from this partnership because it could not identify partners at another stage of its value chain, procuring real estate.

North Star

Attracting paying clients forms a key value chain stage for most of our cases. In Kenya, North Star Alliance learned it is not always possible to exploit revenue-generating opportunities due to scale barriers that lie outside the boundaries of the organization. North Star has developed partnerships with several transport companies, many of which were willing to provide contracts for North Star to conduct annual medical check-ups for their long-haul truck drivers. A manager from Roy Hauliers, which manages a fleet of 250 long-haul truck drivers, told us: “we wanted to give North Star this business so they could do the medical check-ups of our drivers.” North Star was keen to take advantage of the opportunity. However, its clinics are staffed by clinical officers or nurses, but the Ministry of Health guidelines stipulated that check-ups require a doctor. The inability to manage regulatory barriers in North Star’s ecosystem limited its ability to create an alternative revenue stream.

Conclusion

This study offers suggestive analysis of how private sector ventures that target the base of the pyramid in health services delivery use value chain integration strategy. We argue that adopting VCI strategy combined with enabling strategies of an efficiency core and four types of management capabilities helps social enterprises increase their scale.

The ability of health services organizations to draw resources from disparate partnerships with government and private sector actors along different stages of their value chains is central to scaling success. Partnerships along a venture’s value chain are critical precisely because many of the scale barriers lie outside the boundaries of social enterprises. Our research emphasizes why VCI strategy and the enabling strategies of efficiency core and management skills matter for scaling health services delivery to the base of the pyramid.

The study has limitations that require additional research. Our sample is relevant, but small. We omit some value chain partnerships that we were not able to derive from published data and interviews.  Further research comparing organizations that adopted a VCI strategy to those that did not would yield valuable insights. Moreover, inquiry is needed on how social enterprises coordinate their value chain partnerships.

The study offers insights on how social enterprises pursue value chain integration. By using VCI strategy as a practical framework, our research illustrates how and why the broader ecosystem matters for scaling success. The core point is that partners not directly involved in an organization’s core mission can advance or thwart long term success. Hence, global health organizations need to pay close attention to value chain integration strategy and its enabling activities.

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Websites

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Onil Bhattacharyya and Kathryn Mossman, University of Toronto

Contact: Onil Bhattacharyya, onil.bhattacharyya@wchospital.ca

Introduction

Aging populations challenge current models of health service delivery, presenting an opportunity to enhance health systems in low- and middle-income countries (LMICs) and high-income countries (HICs). The number of people 65 years of age or older will triple by 2050, with most of the increase realized in developing countries.¹. This growth will be accompanied by a rise in complex chronic conditions, which require strong self-management and coordination between different levels of care to achieve good outcomes.^2–4 An increase in complex chronic conditions has been associated with a rise in costs historically; however leveraging technologies to redesign health services has the potential to offset increased costs, and provides an opportunity for LMICs and HICs to learn from each other as they experiment with different approaches to provide affordable care.⁵

What can LMICs learn from HICs?

HICs have shown that key features of care models for aging populations with complex needs include careful targeting of patients most likely to benefit; comprehensive assessment of patient needs; care planning and remote monitoring; supporting self-care by patients and families; and coordination of care between providers and families.⁶ LMIC health systems can learn from HICs by devising low-cost models of care that incorporate these key features, emphasizing the development of patient-facing technologies that enable these functions,^7–9 rather than expensive electronic medical records built for administrative purposes.¹⁰ The dearth of medical staff and training programs in care of the elderly in these settings suggests that self-management is a more feasible approach to improving care.

What can HICs learn from LMICs?

The mix of resource constraints, poor performance of existing systems, and a lack of regulation that characterizes LMICs can inspire novel approaches that can be instructive for HICs,⁵ including innovations for elderly populations.¹¹ However, organizations in LMICs are in the early stages of developing innovations focused on the elderly, as shown by a search of the Center for Health Market Innovations (CHMI) database. The CHMI online resource, which catalogues over 1300 innovative programs in LMICs, shows only 35 health programs targeting the elderly.¹²

Despite the low numbers, several key features stand out, particularly in the use of information and communications technology (ICT). Among the CHMI example, 12 use ICTs, often for remote consultations involving online video, phone, or text communications. For example, DoctorFromHome is a program based in India that provides patients with online video consultations with doctors and specialists 24/7 using a web-based platform compatible with desktops, laptops, and mobile devices. Both patients and medical providers can sign up to use this tool, making it easier to add new users and new types of services than if they were based in a specific hospital or clinic.¹³

In another example, Caring Palms Health Care in Nigeria developed a mobile application and website patients can use to schedule medical appointments and home visits, and upload prescriptions for home delivery. They have also designed a subscription plan specifically for the elderly.¹⁴

Another program, Agewell Global, uses ICTs and a peer support network to monitor health outcomes to support the elderly in their homes. Elderly companions visit seniors in their homes and are trained to use the Agewell mobile screening tool to collect information on health and wellbeing. The tool’s algorithms will review collected data, which triggers tailored referral recommendations for medical and social services.¹⁵ A pilot of the program took place in South Africa in 2014 and several additional pilots have launched in the US and Ireland, suggesting that this technology can be deployed in a wide range of contexts.¹⁶ While these approaches are promising, there is much more to be done to address the needs of a rapidly growing global population.

How can technology help redesign health services for the elderly?

There are many new patient- facing technologies, but few target the specific needs of the elderly in either high-income or low-income contexts.¹⁷ High rates of concurrent health conditions⁴ and progressive physical and cognitive decline should be considered in the design of digital tools for this group.¹⁸

A recent study explored the needs of frail elderly and their caregivers that could be addressed by a digital health advisor.^19,20  Four key needs emerged, including the need to manage day-to-day tasks; preserve dignity and connections while adjusting to changes in health status; access accurate and easy-to-understand information on their health; and feel understood by their healthcare providers, family, and friends. Participants suggested features such as a metrics dashboard that collects and displays information on symptoms and signs, tools to connect patients remotely to medical practitioners, a care journal, and a shared calendar and task manager to facilitate coordination between patients and their care team.

A similar study for LMICs could highlight a different set of constraints for the frail elderly, but the desire for dignity, connection, and autonomy is common and not actively supported in most care settings. Digital tools that are inexpensive, durable, use voice and visual interfaces for those with low literacy, and support self-care and engage caregivers are likely to have huge benefit in low resource settings.

Many of the necessary features have been developed, but are found across a range of different tools that only address a subset of a person’s needs.¹⁷ Technological innovations in HICs include a mobile device to improve primary health care for patients with complex chronic disease and disabilities,⁹ a fall-detection sensor for older adults that is linked to a smartphone application,²¹ and a tablet-based tool for waiting rooms that enables complex patients to set priorities for their primary care visit.²² In LMICs, the Chinese Aged Diabetic Assistant is a smartphone application that helps older adults with diabetes self-management, self-monitoring and health education.²³ The majority of chronic disease apps are downloadable for free, so cost may not be a major barrier going forward.¹⁷

Conclusion

Technological innovations provide an opportunity to tailor services to an elderly person’s unique pathophysiology, their social circumstances, and their preferences. They can help manage complex information to support decisions by patients, caregivers, and providers. HICs have provided large subsidies to purchase expensive digital solutions to support administrative functions in large institutions, and are only now adapting them to meet the needs of providers and patients.^24,25

LMICs can skip this phase and support either the development or distribution of digital tools to support patients and caregivers first, and then link them with providers. New models of care could emerge that leverage communities and families more extensively, since the social determinants of health and independence in the elderly extend well beyond health services.²⁶ Digitally enhanced services should prioritize what makes life worth living, facilitate communication with providers, and provide decision-support for people who either cannot access or afford specialized services. The technical capability exists, and tools could be built affordably; however governments will need to support the new models of care delivery that are needed to integrate an elderly person’s system of health with the broader health system.

References

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