TRANSFORMING HEALTH CARE IN LESOTHO Using Digital Health to Overcome Health System Challenges © International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington DC 20433 Internet: www.worldbank.org; Telephone: 202 473 1000 This work is a product of the staff of the World Bank. Note that the World Bank does not necessarily own each component of the content included in this work. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of the World Bank or other partner institutions or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. Nothing herein shall constitute or be considered a limitation or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. 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All queries on rights and licenses should be addressed to the Office of the Publisher, the World Bank, 1818 H Street NW, Washington DC, 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. Cover Design: Theo Hawkins, World Bank Photo adaptation: stock.adobe.com; icap.columbia.edu Transforming Health Care in Lesotho: Using Digital Health to Overcome Health System Challenges Government of Lesotho (Ministry of Health) team (in alphabetical order): Monaheng Maoeng and Mathabo Ntai World Bank team (in alphabetical order): Gabriel Catan, Nejma Cheikh, Noel Chisaka, Marelize Görgens, Wuleta Lemma, Kajali Paintal Goswami, Zara Shubber, Jake Spitz, Katherine Ward, and Thomas David Wilkinson March 2022 This page is for collation purposes. TABLE OF CONTENTS ABBREVIATIONS ...................................................................................................................... vii ACKNOWLEDGEMENTS.......................................................................................................... ix BRIEF SUMMARY ...................................................................................................................... xi EXECUTIVE SUMMARY ......................................................................................................... xv Findings: Maturity of Lesotho’s Digital Health System.......................................... xvii Recommendations: Improving Digital Health in Lesotho......................................... xx Section 1 INTRODUCTION ........................................................................................................ 1 1.1 Purpose of the Report .............................................................................................. 1 1.2 Digital Health in Africa ........................................................................................... 1 1.3 Health Sector in Lesotho.......................................................................................... 3 Section 2 DIGITAL HEALTH MATURITY: ASSESSMENT AND RESULTS ................... 7 Digital Health Assessment Approach ...................................................................... 7 Digital Health Assessments Conducted................................................................... 8 Digital Health Landscape......................................................................................... 9 Digital Health System Maturity in Lesotho: Overview......................................... 10 Digital Health Maturity: Key Aspects ................................................................... 11 Section 3 IMPROVING DIGITAL HEALTH IN LESOTHO ................................................ 16 Digital Environment .............................................................................................. 16 Architecture and Data ............................................................................................ 17 Analytics ................................................................................................................ 17 Applications ........................................................................................................... 17 Section 4 GOING FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP.......................................................................... 19 4.1 Digital Health Dimension 1: Digital Environment................................................ 21 4.2 Digital Health Dimension 2: Architecture and Data ............................................. 22 4.3 Digital Health Dimension 3: Analytics ................................................................. 23 4.4 Digital Health Dimension 4: Applications ............................................................ 24 Section 5 CONCLUSION ........................................................................................................... 29 REFERENCES.............................................................................................................................. 30 GLOSSARY.................................................................................................................................. 33 APPENDICES .............................................................................................................................. 35 v TABLE OF CONTENTS APPENDICES Appendix A Assessment methodology ............................................................................... 35 Appendix B Main diagnostics and most relevant recommendations from previous assessments conducted in Lesotho.................................................................. 37 Appendix C Detailed scoring for Lesotho........................................................................... 41 Appendix D Profile of digital health landscape................................................................... 72 Appendix E Key achievements of the eHealth Strategy (2019‒2023) by strategic area ................................................................................................... 75 Appendix F Principles of participatory design ................................................................... 77 Appendix G Summary of recommendations ....................................................................... 78 Appendix H Summary of priority digital health interventions by health system challenge .................................................................................. 82 FIGURES Figure 0.1 Maturity score by digital health area ............................................................ xvii Figure 1.1 Main PHC challenges in Lesotho..................................................................... 5 Figure 2.1 Purpose of Lesotho’s Digital Health Assessments .......................................... 8 Figure 2.2 Lesotho’s Digital Health Maturity Score ....................................................... 11 Figure 3.1 SWOT Analysis of Digital Health System .................................................... 16 Figure 4.1 Digital Health Strategic outcomes and recommendations ............................. 20 TABLES Table 1.1 Morbidity and mortality: lesotho compared with peer countries ..................... 4 Table 2.1 Existing digital health applications in Lesotho............................................... 13 Appendix table B.1 Diagnostics and recommendations from previous assessments ..................... 37 Appendix table C.1 Indicators of digital maturity in Lesotho ............................................................ 41 Appendix table D.1 Socio-demographics and healthcare system basic information ........................ 72 Appendix table D.2 Digital environment and infrastructure............................................................... 72 Appendix table D.3 Digital health applications and interventions ..................................................... 73 Appendix table H.1 Priority digital health interventions (applications) by health system challenge .................................................................................................. 82 Appendix table H.2 Examples of digital health applications .............................................................. 88 vi ABBREVIATIONS AfDB African Development Bank AU African Union CoE Center of Excellence DHIS-2 District Health Information System eHealth electronic health EMR electronic medical record GDP gross domestic product GoL Government of Lesotho HIV human immunodeficiency virus HMIS Health Management Information System ICT information and communication technologies ID identification document IHR International Health Regulations IoT Internet of Things LIC low-income countries LIMC lower-middle-income countries LMDA Lesotho Millennium Development Agency MCC Millennium Challenge Corporation MCST Ministry of Communications, Science, and Technology MoH Ministry of Health NICR National Identity and Civil Registry PHC primary health care PIH Partners in Health PPP public-private partnerships QMMH Queen Mamohato Memorial Hospital SLA service level agreements TB tuberculosis USAID United States Agency for International Development WBG World Bank Group WHO World Health Organization vii This page is for collation purposes ACKNOWLEDGEMENTS This study is the result of a collaboration between the Lesotho’s Ministry of Health and various individuals whom all made essential contributions to the work presented in this report. Contributors within each organization are listed in alphabetical order. The core study, analysis, and report writing team comprised of Monaheng Maoeng and Mathabo Ntai (Lesotho’s Ministry of Health); and Gabriel Catan, Nejma Cheikh, Noel Chisaka, Marelize Görgens, Wuleta Lemma, Kajali Paintal Goswami, Zara Shubber, Jake Spitz, Katherine Ward, Thomas David Wilkinson (World Bank’s Health, Nutrition and Population Global Practice). The team would like to express its sincere gratitude to the following units of the Lesotho’s Ministry of Health: Information Technology; Planning and Statistics; Disease Control; Procurement Department, and District Health Information Management. These units provided critical data, insights and support. The team would also like to thank other stakeholders from the following institutions for their insights: Baylor College of Medicine Children's Foundation Lesotho, Botho University, the Christian Health Association of Lesotho (CHAL), the Millennium Challenge Corporation (MCC), the National University of Lesotho (NUL), Partners in Health (PIH), the US Centers for Disease Control (US CDC), the United Nations Children's Fund (UNICEF), the United States Agency for International Development (USAID) and the World Health Organization (WHO) Lesotho office. Substantial strategic and technical inputs were also provided by these World Bank colleagues: Yoichiro Ishihara (Lesotho Country Manager), Audrey Ariss (Digital Development Specialist), Laura Di Giorgio (Health Economist), Pia Schneider (Lead Economist), Omer Ramses Zang Sidjou (Senior Health Specialist), Yi Zhang (Health Economist) and Anna Zita Metz (Program Officer). The Global Corporate Solutions Translation, Interpretation and Editing Team (World Bank) provided editorial support. Cover and design: Theo Hawkins (World Bank) ix This page is for collation purposes BRIEF SUMMARY H ealthcare access and service delivery quality have been a persistent challenge in Lesotho. The COVID-19 pandemic has added new challenges and opportunities for change. Among those changes is the need to include digital health solutions and think about how new digital health interventions can be a tool for enhancing efficiency and transforming the way primary healthcare is being provided or delivered in the country. This report, prepared by the World Bank for Lesotho’s Ministry of Health, documents the outcome of an assessment of Lesotho’s digital health system using a unique digital health assessment toolkit produced by the World Bank. The agreed objectives of the assessment were to 1) Clarify the current digital health landscape in Lesotho, 2) Develop a maturity score for Lesotho’s digital health system, 3) Define the strengths, weaknesses, opportunities, and threats (SWOT) facing digital health in Lesotho and 4) Using the results of the assessment, provide recommendations and a phased roadmap of action to define the key strategic actions to move Lesotho’s digital health ecosystem to the next phase of its evolution. Based on the assessment results, 16 strategic recommendations have been made on foundational, functional, and frontier investments to advance the digital health agenda and improve service delivery. The prioritization of the actions has been based on this set of criteria: the most urgent to support PHC transformation, the incomplete actions from the current draft of the e-Health Strategy (2019–2023), and those with the most important long-term impact. This report is a call-to- action to upgrade the current eHealth strategy to a comprehensive digital health strategy with priority interventions, a costed implementation plan, and provisions for future impact assessment geared toward delivering better health in a digital world. CURRENT # SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE DIGITAL ENVIRONMENT R1 Need for Restructure the IT department within Positioning of the MoH Start  IT Department leadership and MOH and expand its role beyond ICT as the guidance, Now Ministry of Health ownership of digital maintenance to promote inclusive digital coordination, and  Ministry of health strategy health policies and strategies across regulatory body on digital Finance internal and external stakeholders. health Assign a dedicated budget for digital health with defined objectives and priorities; align and funnel investments to the right interventions; provide adequate skill mixes; and evaluate interventions. R2 Extensive use of Enrich the Lesotho ICT policy 2021 by Improvement of Start  Ministry of Health mobile, however conducting a health sector connectivity and Now  Ministry of mobile coverage infrastructure assessment. Conduct a electricity supply to Communications, and internet sectoral assessment of infrastructure and ensure the functioning of Science, and connectivity is not connectivity to implement some of the systems and the Technology equally distributed, recommendations made by the Lesotho implementation of digital unstable electricity ICT policy 2021 (currently in draft form). health interventions supply Continued on next page xi TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Continued from previous page CURRENT # SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE R3 Few courses that Collaborate with the Ministry of Creation of a pre-trained Start  Ministry of Health can provide digital Education and Training to implement cadre to assist the work Next  Ministry of health skills at pre-service education of health of the MoH. Potential to Education and levels of pre/in- professionals and health workers on leverage regional Training training digital health, as well in service health knowledge by professionals. The curriculum should coordinating with other include topics in health informatics, data digital health capacity- science for health care, development and building initiatives or implementation of digital health through the digital health interventions, and entrepreneurship to hub (R4). create a pre-trained cadre to assist the work of the MoH. Leverage regional knowledge by coordinating with other digital health capacity-building initiatives. R4 Lack of Promote digital health within the Develop policies and Start All government interoperability with broader e-government context to guidelines for facilitating Next other sectors that enhance the digital economy, including the dialogue and policy are connected to promoting digital ID. The African Union’s making around potential health (i.e., Agenda 2063, ratified by all African investments, research education, housing, countries, aims to ensure that “99.9% of centers, and coordination transportation), people in Africa have a digital legal identity with universities for local limiting a holistic as part of a civil registration process by development of digital perspective of 2030.” The MoH must coordinate with other health to enhance the patients governmental bodies to implement digital ID digital economy to empower patients by linking patient information across facilities. R5 Limited human Formalize digital health collaboration Economies of scale and Start  Ministry of Health resources as with countries within the SADC region to human resources, skills, Later  AU specific people move to form a regional digital health hub, like knowledge, and better Regional neighboring Digital REACH Initiative proposed by practices to improve Economic countries to study USAID for the East Africa Community. readiness to manage Communities and work Lesotho could coordinate efforts and future events, because  AU collaborate with neighboring countries Lesotho is fully through a regional digital health hub, that dependent on South will facilitate sharing of human resources, Africa skills, knowledge, and better practices to improve preparedness and resilience for future health events such as pandemics. ARCHITECTURE AND DATA R6 Nascent Conduct a cybersecurity assessment to Creation of the Start  Ministry of Health development improve cybersecurity and data privacy. necessary safeguards to Now  Ministry of safeguards and Provide technical assistance to develop protect the privacy and Communications, preparedness for policies and guidelines for data privacy, security of data and Science, and digitalization cybersecurity, and data transfer to reduce systems and avoid the Technology vulnerability to cyber-attacks that could disruption of health care Ministry of disrupt the provision of care or jeopardize delivery Justice the privacy of patients’ data. R7 Limited Standard Develop health data governance Improved interoperability Start  Ministry of Health and operating legislation. Develop data governance between the MoH and Next  Ministry of procedures. Lack legislation and standards and define data partners and information Justice, Human of standards for ownership, data transparency, data transfer from facilities Rights & data governance governance, and data management sharing and partner’s programs Correctional information rules within the health into the MoH Services information exchange architecture. Continued on next page xii BRIEF SUMMARY Continued from previous page CURRENT # SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE R8 Limited Expand the health information exchange Facilitation of continuity Start  Ministry of Health interoperability architecture to build a digital health of care by sharing data Next  Partners between health platform (infostructure). Apply the recent among users, health care facilities and WHO guideline “Building a Digital providers, health systems between MoH and Information Infrastructure (Infostructure) for managers, and health partners Health” to build a digital health platform data services using accepted standards and connect with other MoH applications, such as pharmacy systems, DHIS-2, and future human resources and logistics management applications. ANALYTICS R9 Inefficient use of Design and implement a health facility Creation of evidence- Start Ministry of Health data systems to report card based on selected indicators based inputs to support Now monitor, evaluate, for quality improvement. Indicators could decision-making and analyze, and include service delivery, patient satisfaction, resource allocation improve health resources, and wait times to provide insight care and transparency regarding the quality of care at each health facility. R10 Lack of targeted Commission an assessment of primary Matching of digital health Start Ministry of Health digital health health care challenges to identify areas interventions to primary Now interventions that can be improved with digital health care challenges and mechanisms. To be effective and generation of impactful impactful, digital health interventions or outcomes applications should respond directly to primary care challenges that can be identified through assessments like the World Bank’s vital signs profile for primary health care performance improvement (PHCPI). R11 Data is being Commission a data quality assessment. Improved decision Start Ministry of Health collected however, As part of the effort to strengthen making using timely and Now quality is low and surveillance and data collection, the World complete data and not always reliable Bank is currently conducting a process information mining analysis from data collection to data reporting and analysis. This can contribute to a more extensive data quality assessment quality across the health care sector. APPLICATIONS R12 Lack of a costed Design a prioritized and costed plan for Completion of a costed Start  Ministry of Health implementation digital health applications. This plan implementation plan Now  Partners plan of digital should determine which interventions are health relevant, provide an estimate of costs and interventions/applic benefits, assign responsible parties, and ations provide a clear monitoring and evaluation plan. The WHO Digital implementation investment guide (DIIG) could be a valuable resource to guide this work. Continued on next page xiii TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Continued from previous page CURRENT # SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE R13 Fragmentation and Commission technical assistance to Lesotho currently enjoys Start Ministry of Health dependency on support public-private partnerships significant public Now partners for digital (PPP) and service level agreements investment. The current health (SLA) for digital health interventions. global discussions about development SLAs could address the lack of digital PPPs could generate Lack of private health skills and skilled resources in the enough incentive to investment and short term. These should be accompanied attract private sector entrepreneurship by a mid-term strategy to create skilled, in- investment in the house resources. Coordination with WHO country. and IFC could support this activity. R14 Limited number of Design a plan to scale up e-Register Provision of Start Ministry of Health digital health gradually over the next three years to comprehensive care for Next interventions at the transform all existing health programs all community level and into a comprehensive EMR. Expand the e-Register to include aspects such as family planning, chronic diseases, children’s Limited programs health, among others to assure within e-Register comprehensive care for all. R15 Lack of impact Establish an innovation testing Generation of evidence, Start  Ministry of Health evaluation of digital environment for the various measurement of social Next  Private sector health investments interventions and evaluate impact and response, elimination of  Universities feasibility. Testing environments, such as failed interventions, and an innovation and regulatory sandbox or reduction of future living lab, can provide a framework to test implementation costs. solutions in a responsible, monitored, and real-world environment. R16 Lack of evidence Commission feasibility and economic Creation of evidence to Start  Ministry of Health on the cost and evaluation studies of priority digital guide the MoH on future Later  Partners effectiveness of health interventions. Build evidence on investments digital health the cost-effectiveness and cost benefit of interventions digital health interventions such as eRegister, DHIS-2, ECHO to prioritize future investment. xiv EXECUTIVE SUMMARY H ealthcare access and service delivery quality have been a persistent challenge in Lesotho; the COVID-19 pandemic has added new challenges and opportunities for change. The pandemic has increased the need for digital health solutions and how new digital health interventions can be a tool for changing the way primary healthcare is being provided or delivered in the country. This report, prepared by the World Bank for Lesotho’s Ministry of Health (MoH), documents the outcomes of an assessment of Lesotho’s digital health system.1 The agreed objectives of the assessment were the following:  Clarify the current digital health landscape in Lesotho  Develop a maturity score for Lesotho’s digital health system  Define the strengths, weaknesses, opportunities, and threats (SWOT) facing digital health in Lesotho  Using the results of the assessment, provide recommendations and a phased roadmap of action to define the key strategic actions to move Lesotho’s digital health ecosystem to the next phase of its evolution While digital health assessments have been undertaken previously in Lesotho, this assessment adds to the existing body of knowledge by achieving the following:  Provides a comprehensive view of digital health status in Lesotho  Integrates and builds on outcomes of prior assessments to determine the maturity and readiness of all aspects of the digital health ecosystem  Focuses on providing a set of phased recommendations for implementation, emphasizing the ways that digital health systems can support the transformation of primary health care in Lesotho An assessment toolkit developed by the World Bank was used to determine the maturity of Lesotho’s digital health ecosystem. The toolkit focuses on four digital health dimensions— digital environment, architecture and data, applications, and analytics—and draws from other existing digital health assessment tools. The toolkit includes a set of quantitative indicators that define the digital health landscape, desk review and interviews with key informants, and a scoring tool with several indicators that were used that explore issues such as leadership and governance, strategy and investment, legislation, policy and compliance, workforce, standards and interoperability, infrastructure, services, and applications. 1 The report does not provide a comprehensive review of the health sector and health system in Lesotho, as the audience for this assessment is familiar with the country's context. xv TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES A graphic summary of the Digital Health Strategic Outcomes and Recommendations xvi EXECUTIVE SUMMARY FINDINGS: MATURITY OF LESOTHO’S DIGITAL HEALTH SYSTEM The maturity of Lesotho’s digital health ecosystem is in the Nascent/Emerging stage with a score of 1.5 out of 5.0. 2 The Figure 0.1 Maturity score by digital health area Architecture and Data dimension, which represents foundational investments that are essential building blocks for the Applications and Analytics dimensions, demonstrates the highest level of maturity. Implementation of digital health applications and analytics display low maturity and readiness levels for implementation. The Digital Health Environment dimension—which enables the functioning of the others —also requires significant strengthening. Source: World Bank. Areas that require the most significant strengthening are: DIGITAL ENVIRONMENT  Absence of a unified, e-government framework to guide alignment and coordination of existing digital interventions. The absence of a comprehensive e- government strategy causes fragmentation in the country’s digital health system, and misalignment between MoH, other ministries, and partners promotes duplication.  Lack of a legal or policy framework to facilitate data sharing. This often means data is not available in the format, disaggregation, or time frame user demands. There is also no Freedom of Information law nor a government-wide unique ID operating across the system, which could enable coordination beyond the health sector and further efforts to achieve people-centered integration of services.  Suboptimal data hosting by MCST. Constant electricity cuts, connection problems at MoH, and the lack of an uninterruptible power supply (UPS) limit systems’ efficient use and pose significant cybersecurity risks and challenges for the continuity of services. ARCHITECTURE AND DATA  Limited interoperability of systems among different health institutions. Due to the lack of comprehensive guidelines or standards for electronic medical record (EMR) systems, many applications used within or across facilities operate in isolation. For example, even within the MoH information system, there are various unlinked registries (e.g., laboratory results systems and DHIS-2). Moreover, at some partner-run facilities, there is duplication of systems, (e.g., EMRx from the Baylor College of Medicine Children's Foundation Lesotho and e-Register from the MoH), which hampers efforts to provide optimum care to patients. ANALYTICS 2 1=Nascent 2=Emerging 3=Established 4=Institutionalized 5=Advanced xvii TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES  Inexistent community-level data collection. Incomplete population health information is compounded by the inability of village health care workers, who serve the majority of the rural population, to gain access to information systems.  Inadequate digital health literacy among health care workers and decision- makers. The shortfalls are notable in the district and health facilities, where limited effort is made to use digital health solutions such as eRegister and DHIS-2.  Inefficient use of health data systems. Most interventions focus on reporting and are not used to evaluate and analyze health care or improve health care service delivery as there is limited capacity building in areas such as quality of data and data analysis. APPLICATIONS  Duplication of efforts due to vertical health programs run by different partners. Some of these programs (mainly focused on HIV and TB) use digital health interventions and information health systems that are not always interoperable with government systems.  E-government projects funded by partners focused on infrastructure. While this is important, enhancing and funding digital health applications is essential to promote evidence-based public health service delivery. Less effort has been exerted to improve data collection and data quality, to improve electronic medical records and underlying health systems, which are the foundation for developing smart and innovative algorithms for data-driven decision making.  Numerous manual processes and paper-based patient registries. The co- existence of print and electronic systems in some facilities imposes a burden on health workers. Using both systems is time-consuming and creates opportunities for inaccuracy in the use of health information.  Limited availability of patient-level digital health applications. Use of digital health applications would improve outreach and communications.  A shortage of impact evaluations. The inability to efficiently assess the effectiveness, costs, and benefits of digital health interventions, along with the lack of an approved plan and awareness of past failures, resulted in low implementation and hampered the scalability of digital health interventions (at the facility and programmatic level). Improved outcomes could result from expanded and more equitable access to services, improved health service quality, and enhanced readiness for future health-related challenges. Acting on the opportunities (i.e., better infrastructure and connectivity, better governance and structural changes at the IT department in MOH, improve digital health and use of data, development of digital health applications) to better integrate digital health within the health sector could help Lesotho to enhance service delivery. However, the following threats or risks could jeopardize the evolution of digital health in the country:  The mountainous geography can limit the setting up of Internet connectivity and electricity access to health services.  Political instability and a lack of political support delay the advancement of the current eHealth strategy xviii EXECUTIVE SUMMARY  Limited household Internet use that may limit users’ ability to use various digital health products. Internet is not readily available to households in rural areas, and it is expensive.  Limited financial resources reduce opportunities for government-led investments and upgrading of legacy systems and IT hardware  Lack of appropriate human resources increases the low value-added workload of health care workers  Misconceptions and fear about technology among health care workers, and especially among village health care workers, create reluctance to change “ Acting on the opportunities—better infrastructure and connectivity, better governance and structural changes at the IT department in MOH, improve digital health and use of data, development of digital “ health applications—to better integrate digital health within the health sector could help Lesotho to enhance service delivery xix TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES RECOMMENDATIONS: IMPROVING DIGITAL HEALTH IN LESOTHO Based on the assessment analysis, 16 strategic recommendations that span foundational, functional and frontier (innovations) investments have been made, grouped by the digital health system dimension. For each dimension’s strategic recommendations, a roadmap of short-, medium- and long-term actions has been proposed. The prioritization of these actions is based on this set of criteria: the most urgent action to support PHC transformation, the incomplete actions from the current eHealth Strategy (2019–2023), and those actions with the most important long-term impact. Grounded on the most urgent health system challenges and a rapid but impactful approach, the MOH will need to prioritize the following areas in the following years3: FOUNDATIONAL INVESTMENTS  Structural and governance changes at the MoH to position it and promote digital health (R1, R4, R5, R7)  Assessment, planning, and investment in infrastructure enablers such as connectivity, electricity, and data hosting, i.e., cloud (R2, R6, R8)  Development of digital health skills within the MoH system by collaborating with university programs (R3) FUNCTIONAL INVESTMENTS  the scale-up of the register towards a complete electronic medical record system, together with the strengthening of a digital health platform to connect with other information systems (R7, R14)  processes to improve data collection, reporting, and utilization of data for creating insights into systems evidence base, that will support the strengthening of areas such as public health surveillance, that is a priority of the ministry (R9, R10, R11)  scale-up current digital health applications and prioritize the implementation of SMS and mobile technology to increase service delivery through automatic scheduling, referral, and health promotion (R12, R13, R16) FRONTIER INVESTMENTS  Beyond the basic solutions, Lesotho also needs to invest in innovative digital health solutions that could support the efficient delivery of service, improve the quality and results, streamline process, increase access, and reduce costs. These solutions must be evaluated for feasibility and in post implementation (R15). The drafted 2019‒2023 eHealth strategy has been a welcome starting point. However, it has become outdated given that the scenario had changed with the pandemic, relevance of health system resilience and primary healthcare, cyberattacks, and new digital health innovations. It does not include the results of the latest assessments conducted in the country. By joining the dots between the different evaluations conducted in Lesotho, this digital health assessment will be an input to a new digital health strategy (2024‒2028) and help prioritize interventions that can be costed and implemented in the next couple of years to improve 3 The R# in each priority refers to the specific strategic recommendation in the document. xx EXECUTIVE SUMMARY service delivery and promote primary healthcare (PHC) transformation using digital health solutions. The new strategy will:  Create a sustainable and innovative ecosystem with multiple stakeholders such as the private sector, academy, donors and partners, and other government offices  Enhance and coordinate collaboration with other partners, to reduce fragmentation and create alignment around a government-owned strategy and priorities  Increase awareness of the importance of quality data for decision making, accomplished by upgrading digital skills and tools create to more evidence-based knowledge  Design a prioritized and costed plan for digital health interventions using an agile methodology and reducing short and non-scalable projects that generally are duplicated efforts (a phenomenon called “pilotitis”)  Develop and include patient-centered applications as part of the patient journey to increase access, enhance patient empowerment, and improve the quality of care for all This report calls for action to upgrade the current eHealth strategy into a digital health strategy with prioritization of interventions, a costed implementation plan, and measure their impact in the future to deliver better health in a digital world. “ This Digital Health Strategy will prioritize interventions that can be costed and implemented in the next couple of years to improve “ service delivery and promote primary healthcare (PHC) transformation using digital health solutions Photo source: https://www.undp.org/lesotho/blog/lesotho-village-health-workers-road-digital-era xxi This page is for collation purposes SECTION 1 INTRODUCTION Purpose of the Report This report, prepared by the World Bank for Lesotho’s Ministry of Health (MoH), documents the outcome of an assessment of Lesotho’s digital health ecosystem. The agreed objectives of the assessment were the following:  Clarify the current digital health landscape in Lesotho  Develop a maturity score for Lesotho’s digital health system  Define the strengths, weaknesses, opportunities, and threats (SWOT) facing digital health in Lesotho  Using the results of the assessment, provide recommendations and a phased roadmap of action to define the key strategic actions to move Lesotho’s digital health ecosystem to the next phase of its evolution While digital health assessments have been previously undertaken in Lesotho, this assessment adds to the existing body of knowledge in that it achieves the following:  Provides a comprehensive view of digital health status in Lesotho  Integrates and builds on outcomes of prior assessments to determine the maturity and readiness of all aspects of the digital health ecosystem  Focuses on providing a set of phased recommendations for implementation, emphasizing the ways that digital health systems can support the transformation of primary health care in Lesotho Digital Health in Africa As nations race to implement the 2030 Agenda for Sustainable Development (UN, 2015), the COVID-19 pandemic has set back efforts potentially by decades. Yet, due to unprecedented demand, it has also created an opportunity for Africa to rapidly develop digital solutions for health care and enhanced data-driven and evidence-based action. In the grip of the pandemic, digital health has been, is and will be a critical tool for most patients and health service providers and professionals to connect amid stringent lockdown measures, as well as to navigate social distance as the new normal. By the end of 2019, 33 World Health Organization (WHO) Member States in the African region had developed digital health strategies (WHO, 2021).. There has been significant progress in utilizing digital health solutions; however, in most of these countries, digital health solutions are still in the pilot phase. In addition, only a few Member States have complied with the implementation methodology recommended in the WHO National eHealth Strategy Toolkit, which aims to facilitate the scale-up and sustainability of digital health (WHO, 2012). Challenges in the region include insufficient digital health leadership capacity at the national level, limited multisectoral arrangements for digital health, inconsistent 1 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES adoption of standards and interoperability frameworks, and limited data protection and system security regulations. Other notable challenges include inadequate financial resources and the low level of health worker involvement in digital health. At the regional level, a failure to share evidence limits the development of best practices. To mitigate these challenges, WHO adopted a global digital health strategy in 2020 (WHO, 2021) to advance and apply digital health technologies toward achievement of Goal 3 of the Sustainable Development Goals (SDG), namely “good health and well-being,” as well as the other health-related SDGs (UN, 2015). It also aims to promote research, improve evidence and information sharing, as well as promote best practices in digital health to ensure a solid foundation for national scale-up of digital health services. As part of the African Union’s Agenda 2063: The Africa We Want, the Digital Transformation Strategy for Africa (AU, 2015) will build on the existing initiatives and frameworks, such as the Policy and Regulatory Initiative for Digital Africa (PRIDA), the Program for Infrastructure Development in Africa (PIDA), the African Continental Free Trade Area (AfCFTA), the African Union Financial Institutions (AUFIs), and the Free Movement of Persons (FMP), to support the development of a Digital Single Market (DSM) for Africa, as part of the integration priorities of the African Union. The Digital Transformation Strategy is also designed explicitly to support and connect with the AfCFTA. Its central objective is for Africa to use digital technologies and innovation to transform the continent, generate inclusive growth, create jobs, and ensure African ownership of digital technologies. To do this, it aims to spur the creation of a Digital Single Market in Africa by 2030. The following are some of its digital health-related strategic objectives:  Entry into force of the African Union Convention on Cyber Security and Personal Data Protection by 2020 and adoption by all Members States of a complete set of legislation covering e-Transactions, Personal Data Protection and Privacy, Cybercrime, and Consumer Protection  Development of inclusive digital skills and human capacity across the digital sciences, judiciary, and education, both technical and vocational, to lead digital transformation, including coding, programming, analysis, security, blockchain, machine learning, artificial intelligence, robotics, engineering, innovation, entrepreneurship, and technology policy and regulation  Design of a sector approach to the digitalization of the agriculture, health, and education sectors  Creation of enabling conditions so that 99.9 percent of citizens of African countries have a digital legal identity as part of a civil registration process by 2030 Africa’s digital landscape has many internal and external stakeholders. The World Bank Group (WBG) Digital Economy for Africa (DE4A) flagship initiative supports the digital transformation strategy prepared by the African Union (AU) (World Bank Group, 2021) and aims to ensure that every individual, business, and government will be digitally enabled by 2030. The DE4A initiative recognizes that the digital economy can help accelerate achievement of the UN Sustainable Development Goals (SDGs) and the World Bank Group’s twin goals. 2 INTRODUCTION The WHO has developed a framework to guide the implementation of the global digital strategy among its Member States in Africa (WHO, 2021). The framework considers Member State and regional contexts and presents overarching goals, SMART objectives, and strategic targets for actualizing elements of the global strategy in the African region. It outlines guiding principles, including action points, to ensure effective implementation among the Member States. In addition, Article 7 of the Southern African Development Community (SADC) Protocol on Health (SADC, 1999) requires the sharing of health data and the establishment of a regional indicators database (SADC, 1999), requirements that are ever more important as the regional economy becomes more integrated. The COVID-19 pandemic has exposed health system failures worldwide, generating powerful momentum for change. Africa is proving fertile ground for telehealth providers as the pandemic response has enabled the rapid expansion of telemedicine services, by 50 to 175 times the pre-pandemic number of telehealth patients (Henry,2020). Increasingly, social media tools such as WhatsApp are also being used to provide these services., In Kenya for example, telemedicine is being used as a mental health tool to help citizens through daily strains, such as isolation, unemployment, and a disrupted social life, triggered by the pandemic (Adepoju,2020). Digitization also offers African countries the opportunity to strengthen health systems and reimagine primary health care services. Health Sector in Lesotho This section contains relevant information for achieving the report’s objectives; however, it does not provide a comprehensive review of the health sector and health system in Lesotho, as the audience for this assessment is familiar with the country’s context. Lesotho has a population of 2.1 million, 71 percent of whom live in rural areas (2020).4 The per capita gross national income was US$ 3,030 in 2021 (in PPP current international dollars).5 Approximately 75 percent of Lesotho’s population live or are at risk of living in poverty. The country has close economic and geographic linkages to South Africa. Total government health spending has increased in the past decade and is higher than in many other African countries. Health expenditure as a percentage of GDP reached 9.28 percent in 2018, which is considerably higher than the average for Sub-Saharan Africa (5.16 percent) and upper-middle-income countries (5.82 percent).6 Despite high levels of expenditure on health, health care access and service delivery quality have posed a persistent challenge in Lesotho. As Table 1.1 shows, Lesotho ranks below many of its peers in terms of morbidity and mortality. Given its considerably higher expenditure on health, Lesotho could significantly improve the quality and efficiency of health care in the country and increase the value of investment in this area. 4 World Bank Group, World Development Indicators database, Population, total-Lesotho: Various sources, 2020. 5 World Bank Group: GNI per capita, PPP (current international $) – Lesotho: International Comparison Program, World Bank | World Development Indicators database, World Bank | Eurostat-OECD PPP Programme. 6 World Bank Group: Current health expenditure (% of GDP) – Lesotho: World Health Organization Global Health Expenditure database. 3 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Table 1.1 Morbidity and Mortality: Lesotho compared with Peer Countries Age-standardized death rates, YLL rates, YLD rates, and life expectancy at birth and health-adjusted life expectancy at birth for1990 and 2010, both sexes combined Source: Adapted from Institute for Health Metrics and Evaluation (IHME) (2020).7 Note: HALE = Health-adjusted life expectancy; LE = Life expectancy; YLD = Years lived with disability; YLL = Years of life lost. Achieving universal, comprehensive primary health care in Lesotho has been a government priority at various points over the past two decades. The MoH has adopted the Framework for the implementation of the Ouagadougou Declaration on Primary Health Care and Health Systems in Africa (World Health Organization 2009). The National Health Policy 2016 and the National Health Strategic Plan (NHSP 2017‒22) were both developed based on the principles of the Ouagadougou framework. 7 Global Burden of Disease (2010), GBD Profile: Lesotho, https://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_lesotho.pdf 4 INTRODUCTION Figure 1.1 Main PHC challenges in Lesotho Source: Prepared by the authors based on previous World Bank assessments, discussions with MoH, and key stakeholder interviews. The government is the primary provider of health care services in Lesotho. Other providers are privately owned or run by smaller, nongovernmental organizations and consist of a network of private surgeries, nurse clinics, and pharmacies providing health care, including dispensaries of medicines. Each of Lesotho’s ten administrative districts has at least one secondary-level hospital, which is physician-led and serves as a referral facility for all health centers in the district. Instead of offering specialized services, most district hospitals offer primary health care (PHC) services, which are supposed to be provided by health centers and health posts. The national tertiary care hospital in Maseru, the capital, is the only government hospital offering intensive care. Health care in Lesotho is predominantly nurse- driven, with an average of 11.58 nurses per doctor. About 90 percent of private, for-profit health facilities are situated in the four large districts of Maseru, Berea, Mafeteng, and Leribe, making access to health services difficult for people who cannot afford private care or who live in rural areas. Although the role of community health workers (CHWs) who provide PHC services in the country dates back as far back as 1979, access to critical primary health care services remains low. Lesotho’s health care access and quality score in 2016 was 32 (as measured by the Institute for Health Metrics and Evaluation (IHME) on a scale of 0 to 100), indicating considerable room for improvement. Digital health, combined with clearly defined and reimagined policies and outcomes, can be a tool for effecting change in how primary health care and health other services are delivered. Implementing digital health interventions can support the transformation of the country’s health care service delivery to ensure more inclusive, comprehensive, patient-centered quality care for all, and reduce inequity. . 5 This page is for collation purposes SECTION 2 DIGITAL HEALTH MATURITY: ASSESSMENT AND RESULTS A n assessment of the digital environment, architecture and data, applications, and analytics was performed to determine the maturity and readiness of the country’s digital health system for implementing and advancing digital health for healthcare services delivery. Digital Health Assessment Approach In deciding on an assessment approach, the World Bank aimed to build on existing assessments, take a comprehensive approach to digital health maturity, ensure that the assessment would yield a digital health maturity index for Lesotho (to contribute to the Global Digital Health Index scores for multiple countries), and focus on priority areas for the implementation plan. With these principles in mind, the World Bank developed a hybrid digital health maturity assessment tool that draws on several existing digital health tools.8 More details about the World Bank’s approach to the assessment are available in its Digital Health Assessment Toolkit Guide. The score derived from the assessment reflects the digital health maturity across four dimensions: Digital Environment, Architecture and Data, Applications, and Analytics. Within each dimension, several indicators were used (75 in total, some drawn from existing digital health assessments tools and others developed where gaps existed) that explore various topics such as leadership and governance, strategy and investment, legislation, policy and compliance, workforce, standards and interoperability, infrastructure, and services. Based on the status of each aspect of the digital health system, the indicator is allocated a score (out of 5). Scores are aggregated and normalized, to derive an average score out of 5 for each of the four dimensions and for the overall digital health system. In addition, using the indicators drawn from the Global Digital Health Index, Lesotho’s digital health index is calculated for comparison against other countries. Appendix A contains more information about the assessment methodology and information sources. The World Bank team—working closely with the MoH—used inputs from various digital health assessments that have already been completed in the country, as well as a desk review of existing documents and reports and key informant interviews, with the following objectives: a. Populate a digital health landscape profile about the key features of digital health in Lesotho (see section 2.3) b. Rate each of the 75 indicators across the four dimensions to determine a digital health maturity score for Lesotho as a whole and for each of the four dimensions 8 See the Navigator for Digital Health Capability Models for more information about each of the existing tools. https://wiki.digitalsquare.io/index.php/Navigator_for_Digital_Health_Capability_Models. 7 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES (section 2.4), and describe key aspects of each dimension and digital health readiness (section 2.5 and section 3) c. Determine Lesotho’s Digital Health Index, per the global set of indicators (section 2.4) d. Using the results documented in sections 2.3 and 2.4, undertake a SWOT (strengths, weaknesses, opportunities, and threats) analysis of the digital health system in Lesotho (section 3) e. Propose strategic outcomes, recommendations, and priority actions for implementation (section 4) Digital Health Assessments Conducted Various digital health assessments have been undertaken in Lesotho (figure 2.1). These assessments have had specific areas of emphasis, but none has focused on the overall digital health system writ large. For example, the UNICEF Lesotho Data Requirements Analysis and Data Mapping (UNICEF, 2018) focuses on analytical maturity and data use in the country. Similarly, the USAID/MCC/RTI Lesotho ICT Assessment is focused primarily on the ICT infrastructure and architecture, although it explores data use and different digital health interventions or applications. The ICAP–MOH Rapid assessment (ICAP) of the HMIS in Lesotho examined policies and guidelines, data flow and quality, paper and electronic health information systems, infrastructure and human resource capacities at the central, district, and health facility levels, to identify areas requiring an HMIS Strategic Plan 2018–2022 focused on HMIS usage and improvements in the country. Appendix B compiles the findings and recommendations for some of these assessments. Figure 2.1 Purpose of Lesotho’s Digital Health Assessments Source: World Bank 8 DIGITAL HEALTH MATURITY: ASSESSMENT AND RESULTS Digital Health Landscape As part of the assessment toolkit, a landscape profile was conducted that collects sociodemographic data, digital indexes, and connectivity and quantitative systems indicators that helped contextualize the findings from the desk review and interviews and the maturity score (section 2.4).9 A detailed landscape profile that compares Lesotho to other countries in the region, can be found in appendix D. Lesotho possesses an extensive, although not always reliable, mobile infrastructure. One of the strongest elements of the digital health landscape is that Lesotho has extensive mobile coverage, especially for 2G and 3G networks (approximately 90 percent). Other networks, such as 4G, are being used in parts of the country (45 percent), and 5G and fiber optic technologies are emerging. Around 60 percent of Basotho have smartphones, and two mobile companies are currently providing infrastructure and connectivity. These types of phones help boost the use of social media platforms. While Lesotho has a large network and mobile coverage, Internet use by individuals is limited (30 percent) and access to electricity (47 percent) are still low compared to other countries in the area (50 percent and 72 percent on average, respectively).10 The country also ranks low on global digitalization indexes such as the UN e-government development index (135 of 193) and the ITU–ICT development index (133 of 176). Most digital health interventions in Lesotho are related to health information systems, such as the DHIS-2 (used for program monitoring and reporting), and an electronic medical record (EMR) system called e-Register that covers only HIV- and TB-related programs and patients. All 182 health facilities have an Internet connection and use standardized operating procedures for data collection and transfer between the health facility, district, and national levels at the MoH. -A Health Information Exchange is now fully operational, so data at local Health Facilities servers is shared across all Health Facilities, through e-Register. While e-Register is not yet linked to laboratory information, radiology images, or other relevant patient-level information and programs, it is expected to do so in the near future11. In addition, at the national level, electronic medical billing is inexistent, logistics management systems are only partially digitalized and human resources systems are manual and rarely updated. There is currently an initiative to connect pharmacy information and drug procurement to the e-Register and a plan to move to a paperless system at health facilities, using specific parameters and data quality standards established by the MoH. Finally, as shown in section 2.5, there are few applications available to provide patients with appointment reminders, telehealth, treatment adherence and decision support systems, intelligent dashboards, or patient monitoring solutions at the health facility or national level. There is a nascent use of cloud services. The MoH is currently using Amazon Web Services cloud (through ICAP) to host the Health Information Exchange, including an interoperability 9 For a full list of the indicators and their value see appendix B. 10 Average of Botswana, Eswatini, Namibia, and South Africa. 11 Previous experiences with EMR systems have prompted the need to build the EMR in smaller modules and individual programs. It is expected to scale up the system in the near future. 9 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES server, Master Patient Index, shared health records, and the DHIS-2. Only some information that supports the e-Register is hosted there, which means there is still data on local servers at health facilities that is not being shared across facilities. With support from Microsoft, the MoH is piloting the transfer of data to Microsoft Azure cloud services, under a government initiative to transfer data into one cloud instead of siloed initiatives and improve data sharing. Some local universities offer information systems degrees. The National University of Lesotho and Botho University offer information systems and computer science degrees. The National Health Training College also provides in service training. Still, these degrees or trainings do not focus on digital health implementation, data science for data analysis, or digital health leadership. In addition, continuous education and post training should be strengthened. Use of data mainly for reporting purposes. While data is collected at several points and then transferred to district and national level, the use of it is mainly for reporting or descriptive purposes and data is shown at aggregated level. The use of data for predictive analytics, decision support or prescriptive recommendations is inexistent, limiting the potential value of it. Above all, data quality is generally low and reliability is not always high. Digital Health System Maturity in Lesotho: Overview A maturity score for Lesotho was produced using the digital health assessment tool created by the World Bank. The score for each of the 75 indicators can be found in appendix C (or click here to open the Excel file), and the digital health maturity score is summarized in figure 2.4. The assessment revealed the following: a. “Architecture and Data” has the highest level of maturity: these foundational investments are essential building blocks for the Applications and Analytics dimensions. World Bank Digital Health Maturity Score (0 to 5) 1.5 Digital Environment 1.5 Architecture and Data 2.0 Applications 1.1 Analytics 1.6 b. Implementation of both digital health applications and analytics is at a low level of maturity. c. The Digital Environment dimension—which enables the other dimensions—is also weak. d. Lesotho’s overall digital health maturity is at the Nascent to Emerging stage, with a score of 1.5. 10 DIGITAL HEALTH MATURITY: ASSESSMENT AND RESULTS Figure 2.2 Lesotho’s Digital Health Maturity Score Source: World Bank e. Lesotho’s digital health index receives a score of 1.5 and it can be translated into Phase 2 (according to the Global Digital Health Index framework), with it scoring as follows in relation to each one of the Global Digital Health Index dimensions Global Digital Health Index overall (out of 5) Phase 2 Leadership and governance Phase 2 Strategy and investment Phase1 Legislation, policy, and compliance Phase 1 Workforce Phase 1 Standards and interoperability Phase 2 Infrastructure Phase 1 Services and applications Phase 3 Digital Health Maturity: Key Aspects One of the key features of the Digital Environment dimension is the existence of a drafted digital health strategy in Lesotho. Digital Health Strategy Lesotho’s eHealth Strategy 2019‒2023 was drafted to guide the application of eHealth initiatives to improve service delivery and health outcomes.12 The eHealth Strategy focused on seven priority strategic areas: ICT Services and Applications, Leadership and Governance, Strategy and Investment, Infrastructure, Standards and Interoperability, Legislation, Policy, Compliance, and Workforce. Appendix E summarizes key achievements in each of these seven strategic areas. 12 Lesotho has no official digital health strategy currently, however, there has been efforts to implement some of the actions during the past years. 11 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Development of the eHealth Strategy was preceded by a rapid assessment of eHealth readiness conducted by WHO during a scoping mission, along with other assessments and recommendations made by various entities, such as the African Development Bank (AfDB) e-Government project. As the drafted strategy covered the period 2019‒2023, the following elements should be taken into account during the preparation/development of any succeeding future strategy:  The strategy was designed prior to the COVID-19 pandemic and thus did not include the new challenges and needs imposed by the pandemic and future health emergencies  The current strategy does not focus on primary care transformation and system re- design, but on ICT, systems, and infrastructure, which are essential, but not comprehensive. Aspects of the digital health ecosystem that are critical to the success of efforts to transform health care in Lesotho, that are not included in the current strategy, include the following:  Data governance standards, associated regulations, and security measures to share and protect health data  Approaches to leveraging the use of digital health interventions/applications for clients, providers, and health care administrators, and  The use of data, advanced analytics, and algorithms for evidence-based decision making  The strategy lacks a robust assessment of cybersecurity and cloud services, which are currently of interest to the government  The strategy lacks a costed implementation plan  The strategy has not received final approval but has been publicly disseminated among stakeholders and partners. The IT department has been implementing ad-hoc the current drafted strategy since 2019‒20. Thus, a midterm and final review are highly recommended as part of the next steps, prior to the subsequent strategy cycle. Scope of Current Digital Health Applications in Lesotho Some digital health interventions or applications are currently being implemented in Lesotho, as detailed in table 2.1. As is clear from the list, few of the interventions have been nationally implemented. 12 DIGITAL HEALTH MATURITY: ASSESSMENT AND RESULTS Table 2.1 Existing Digital Health Applications in Lesotho TYPE OF DIGITAL STATUS AS OF HEALTH NAME NOVEMBER 2022 INTERVENTION DESCRIPTION DHIS-2 Running (national Health Information DHIS-2 is the primary reporting system in Lesotho. level) Management System The information is entered by health facilities, validated by district managers, and used nationally for decision making. It is fully integrated with e- Register. Data is shown as aggregated and not at the patient level. Patient level data is in the eRegister which aggregates that data monthly and posts it into the DHIS2 DISA Running (national Laboratory information The system shows patient-level laboratory information level) system and is connected to DHIS-2 through aggregated indicators and not at the patient level. BSIS Running (national Blood safety and Reports on blood supplies and distribution. Not level) inventory information currently connected to DHIS-2 system e-Register Running (national Proxy for EMR The e-Register is used to enter information at the level) patient level. It is used in all health facilities; however, it only includes TB and HIV patients and related information on other programs that cross issues with TB and HIV. It is connected to information collected by pharmacies. EMRx Running at Baylor EMR There are plans to connect EMRx with e-Register. College of Medicine Currently, data clerks must enter information manually Children's in both systems. Foundation Lesotho OpenMRS Running at Partners EMR There are plans to connect OpenMRS with e- in Health (PIH) Register. Currently, data clerks must enter information facilities manually in both systems. U-report Running throughout Reporting of health U-report uses SMS technology to engage young the country system feedback by people to provide feedback on several health-related clients topics. Algorithms for Running at some PIH Screen clients by risk Some partners are using artificial intelligence radiology facilities or another health algorithms to detect TB by X-ray as a decision status support system. COVID Citizen In implementation Transmits untargeted Considering the pandemic, the National COVID-19 App phase (national level) health information to an Secretary (NACOSEC) will start implementing a undefined population community engagement app (COVID Citizen App) to Transmits targeted provide information on COVID-19 cases, notifications, alerts and reminders to results, and other information. client(s) BKM (Bophelo Running (Quthing Surveillance/HMIS The first zero rated android system used by Village ka Mosebeletsi) and Mokhotlong) System Health Care Workers with provided tablets for App extended to Mohales capturing COVID-19 alerts at community level. Hoek, Maseru, Currently all VHW tools have been developed into the Leribe app whereby monthly reports are then posted to Pilot DHIS2 aggregated report at facility level monthly BONOLOMED Pilot Pharmacy system A system that sends patients’ medication to lockers in specific locations so they can avoid going into a health facility or to the pharmacy. The patient receives a code with which to activate and open the locker. Table continued on next page 13 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Table 2.1 Existing Digital Health Applications in Lesotho (continued) TYPE OF DIGITAL STATUS AS OF HEALTH NAME NOVEMBER 2022 INTERVENTION DESCRIPTION M-mama Pilot Coordinates “A groundbreaking emergency transport system emergency response utilizing mobile technology and [the] mobile money and transport system M-Pesa to reduce maternal and neonatal mortality rates. It provides a toll-free number and 24/7 call center to connect women who experience complications in pregnancy, labor, or with a newborn to either an ambulance or to a fleet of ‘ambulance taxis.’” (Vodafone, 2020) ECHO Pilot Consultations for case ECHO is a tele-mentoring application that connects management between experts and health care workers (learners) to share health care provider(s) support, guidance, and feedback on patients’ cases. VAXPass Not yet implemented Digital vaccination This system was recently developed to provide digital certification vaccination certificates. Source: World Bank. 14 This page is for collation purposes SECTION 3 IMPROVING DIGITAL HEALTH IN LESOTHO B ased on the results discussed in section 2, the assessment team conducted a SWOT analysis of Lesotho’s current digital health system. Figure 3.1 SWOT Analysis of Digital Health System Source: World Bank. The SWOT analysis identified weaknesses and threats that, if addressed, would enable Lesotho to move into the next stage of digital health maturity, enhancing the country’s ability to further leverage digital health to advance its health priorities and improve outcomes. The following key aspects of the weaknesses and threats were identified: DIGITAL ENVIRONMENT  Absence of a unified, e-government framework to guide alignment and coordination of existing digital interventions. The absence of a comprehensive e- government strategy causes fragmentation in the country’s digital health system, and misalignment between MoH, other ministries, and partners promotes duplication.  Lack of a legal or policy framework to facilitate data sharing. This often means data are not available in the format, disaggregation, or time frame user demand. There is also no Freedom of Information law nor a government-wide unique ID operating across the system, which could enable coordination beyond the health sector and further efforts to achieve people-centered integration of services. 16 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP  Suboptimal data hosting by MCST. Constant electricity cuts, connection problems at MoH, and the lack of an uninterruptible power supply (UPS) limit systems’ efficient use and pose significant cybersecurity risks and challenges for the continuity of services. ARCHITECTURE AND DATA  Limited interoperability of systems among different health institutions. Due to the lack of comprehensive guidelines or standards for electronic medical record (EMR) systems, many applications used within or across facilities operate in isolation. For example, even within the MoH information system, there are various unlinked registries (e.g., laboratory results systems and DHIS-2). Moreover, at some partner-run facilities, there is duplication of systems, (e.g., EMRx from the Baylor College of Medicine Children's Foundation Lesotho and e-Register from the MoH), which hampers efforts to provide optimum care to patients. ANALYTICS  Inexistent community-level data collection. Incomplete population health information is compounded by the inability of village health care workers, who serve the majority of the rural population, to gain access to information systems.  Inadequate digital health literacy among health care workers and decision makers: The shortfalls are notable at the district and health facility levels, where limited effort is made to use data to improve quality of care.  Inefficient use of health data systems: Most interventions focus on reporting and are not used to evaluate and analyze health care or improve health care service delivery. APPLICATIONS  Duplication of efforts due to vertical health programs run by different partners. Some of these programs (mainly focused on HIV and TB) use digital health interventions and information health systems that are not always interoperable with government systems.  E-government projects funded by partners focused on infrastructure. While this is important, enhancing and funding digital health applications is essential to promote evidence-based public health service delivery. Less effort has been exerted to improve data collection and data quality, to improve electronic medical records and underlying health systems, which are the foundation for developing smart and innovative algorithms for data-driven decision making.  Numerous manual processes and paper-based patient registries. The co- existence of print and electronic systems in some facilities imposes a burden on health workers. Using both systems is time-consuming and creates opportunities for inaccuracy in the use of health information.  Limited availability of patient-level digital health applications. Use of digital health applications would improve outreach and communications.  A shortage of impact evaluations. The inability to efficiently assess the effectiveness, costs, and benefits of digital health interventions, along with the lack of an approved plan and awareness of past failures, resulted in low implementation 17 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES and hampered the scalability of digital health interventions (at the facility and programmatic level). Acting on opportunities to better integrate and leverage digital health within the health sector could help Lesotho move quickly to the next digital health maturity stage and enhance service delivery. Improved outcomes could result from expanded and more equitable access to services, improved health service quality, and enhanced readiness for future health-related challenges. However, the following threats or risks could jeopardize the evolution of digital health in the country:  The mountainous geographical characteristics limit access to health services in distant areas and reliable infrastructures, such as Internet connectivity and electricity  There is limited household Internet use  Political instability and a lack of political support delay the advancement of the current eHealth strategy  Misalignment between MoH and partners’ needs and objectives impede buy-in and promotion of any national strategy  Limited financial resources reduce opportunities for government-led investments and upgrading of legacy systems and IT hardware  Limited human resources increase the low value-added workload of health care workers  Misconceptions and fear about technology among health care workers, and especially among village health care workers, create reluctance to change  Limited data collected at the community level results in incomplete information and population health analytics In the East region, for children under 5 years old it is estimated that up to 80% of uncomplicated and 65% of severe malaria cases are never diagnosed, and in adults up to 70% of uncomplicated cases and 60% of severe malaria cases are never diagnosed 18 SECTION 4 GOING FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP T he current 2019‒2023 eHealth strategy has been a welcome starting point. This digital health assessment will provide input for the development of the next digital health strategy (2024‒ 2028) and help the government prioritize interventions geared toward improving service delivery and promoting primary health care transformation. The new strategy should include the following objectives:  Create an interoperable ecosystem with multiple stakeholders, such as the private sector, academia, donors and partners, and other government offices  Enhance collaboration with partners to reduce fragmentation and create alignment around a government-owned strategy and priorities  Increase awareness of the importance of quality data for decision making, accomplished by upgrading digital skills and tools to create more evidence-based knowledge  Design a prioritized and costed plan for digital health interventions using an agile methodology and reducing “pilotitis”  Develop and include patient-centered applications as part of the patient journey to increase access, enhance patient empowerment, and improve the quality of care for all Based on the SWOT analysis, 16 strategic recommendations have been made, grouped by digital health system dimension (figure 4.1). For each dimension’s strategic recommendations, a roadmap of short-, medium-, and long-term actions has been proposed. The recommendation number (R#) can be used to link the recommendations to the priorities discussed and the actions associated with each dimension. Prioritization of these actions is based on the following criteria: most urgent action to support PHC transformation, incomplete actions from the drafted eHealth Strategy (2019–2023), and actions with the most significant long-term impact. Appendix E provides a summary of all recommendations. 19 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Figure 4.1 Digital Health Strategic Outcomes and Recommendations Source: World Bank. 20 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATIONROAD MAP DIGITAL HEALTH DIMENSION 1: DIGITAL ENVIRONMENT Strategic Outcome 1 Create a sustainable and innovative ecosystem with clear guidance from the government, involving multiple stakeholders, such as the private sector, academia, donors and partners, other government offices, and collaboration with neighboring countries (i.e., South Africa, Eswatini) to strengthen, develop, and advance digital health and provide an institutionalized framework with the necessary incentives to foster collaboration. Recommendations R1. Restructure the IT department within MOH and expand their role beyond ICT maintenance to promote inclusive digital health policies and strategies across internal and external stakeholders. Assign a dedicated budget for digital health with defined objectives and priorities to provide direction; align and funnel investments to the right interventions; provide adequate skill mixes; and evaluate interventions. Appendix D describes some participatory design principles that are relevant for this recommendation. R2. Enrich the Lesotho ICT policy 2021 by conducting a health sector infrastructure assessment. Conduct a sectoral assessment of infrastructure and connectivity to implement some of the recommendations made by the Lesotho ICT policy 2021 (currently in draft form). This assessment should explore plans to move to sustainable green energy to enable a consistent electricity supply for facilities and data centers, while reducing the climate impact. R3. Collaborate with the Ministry of Education and Training to implement pre- service education of health professionals and health workers on digital health, as well in service health professionals. The curriculum should cover health informatics, data science for health care, development and implementation of digital health interventions, and entrepreneurship to create a pre-trained cadre to assist the work of the MoH. Leverage regional knowledge by coordinating with other digital health capacity-building initiatives. R4. Promote digital health within the broader e-government to enhance the digital economy, including promoting digital ID. The African Union’s Agenda 2063, ratified by all African countries, aims to ensure that “99.9% of people in Africa have a digital legal identity as part of a civil registration process by 2030.” The MoH must coordinate with other governmental bodies to implement digital ID to empower patients by linking patient information across facilities. R5. Formalize digital health collaboration with countries within the SADC region to form a regional digital health hub, like Digital REACH Initiative proposed by USAID for the East Africa Community. Lesotho could coordinate efforts and collaborate with neighboring countries through a regional digital health hub, that will 21 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES facilitate sharing of human resources, skills, knowledge, and better practices to improve preparedness and resilience for future health events such as pandemics Roadmap of Actions START NOW START NEXT START LATER R1. Establish MoH coordination R1. Develop standard operating R3. Establish synergies with institutions structures to evaluate the actions procedures (SOPs) for the current of higher learning to promote taken so far in digital health and eHealth strategy training in digital health skills guide the development of the R4. Establish a national digital health R4. Collaborate with the Ministry of subsequent strategy (2024‒28) standards body Home Affairs to link shared health R1. Establish a Technical Working R5. Source funding from stakeholders records and the Home Affairs Group to coordinate and development partners to NICR system to enable unique implementation activities for the develop a resource mobilization identification/digital ID of patients new digital health strategy plan via ID cards (2024‒28) R5. Develop and implement a plan for R4. Document requirements for digital R1. Determine the cost of the new digital health advocacy campaigns health integration into e- digital health strategy (2024‒28) governance R1. Review the current national health R5. Develop a retention policy for the policy to include digital health digital health workforce R1. Develop a monitoring and evaluation framework for the new eHealth strategy R2. Commission a health sector infrastructure assessment R4. Promote the digital health strategy to seek buy-in across all MoH departments and government sectors and stakeholders) DIGITAL HEALTH DIMENSION 2: ARCHITECTURE AND DATA Strategic Outcome 2 Enhance and coordinate the collaboration with other partners to create an enabling and secure environment that will assure the continuity of care. The fragmented landscape with multiple vertical programs, each using a different system, adds complexity when identifying patient journeys and providing continuity of care and obstructs a holistic perspective of patients. Efforts to make systems interoperable must learn from experiences with previous initiatives, considering standards, data privacy, and the security of data flows. Recommendations R6. Conduct a cybersecurity assessment to improve data privacy. Provide technical assistance to develop policies and guidelines for data privacy, cybersecurity, cloud services and data transfer, to reduce vulnerability to cyber-attacks that could disrupt the provision of care or jeopardize the privacy of patient data. R7. Develop legislation for health data governance. Develop data governance legislation and standards and define data ownership, data transparency, and data management, sharing information rules within the health information exchange architecture. 22 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP R8. Expand the health information exchange architecture to build a digital health platform (infostructure). Apply the recent WHO guideline “Building a Digital Information Infrastructure (Infostructure) for Health” to build a digital health platform using accepted standards, and connect with other MoH applications, such as pharmacy systems, DHIS-2, and future human resources and logistics management applications. Roadmap of Actions START NOW START NEXT START LATER R7. Develop national digital health R6. Assess compliance with R7. Establish an accreditation system standards (R7) cybersecurity standards for organizations and institutions to R7. Conduct an audit of all laws and R6/8. Establish a secondary or failover foster compliance with digital policies pertaining to health service cloud hosting platform for high health standard operating delivery in the country to identify demanding systems by Mirror procedures areas to incorporate digital health Cloud servers with local servers R8. Assess the requirements for digital R6/8. Improve network and health interoperability infrastructure monitoring, support, R8. Upgrade mail systems to security, and maintenance accommodate both voice and reporting by exploring different video conferencing, and train users monitoring software on their use R8. Extend the network to all health R7/8. Incorporate digital health in training facilities programs for health personnel R8. Improve government network offered by higher education uptime to over 95% by December institutions 2023 DIGITAL HEALTH DIMENSION 3: ANALYTICS Strategic Outcome 3 Increase awareness of data utilization and data quality for decision making by upgrading digital skills and tools and creating more evidence-based knowledge. There is a critical need to build a cadre of well-informed, effective leaders who are trained to understand the potential of data and the impact of digital health, and who can successfully lead and execute digital health transformation initiatives. This includes improvement of the data collection process and data quality measures that can support surveillance activities as well as potential analytics (supply- and demand-side) for informed decision making. Recommendations R9. Design and implement a health facility report card based on select indicators of quality improvement. Indicators could include service delivery, patient satisfaction, resources, and wait times to provide insight and transparency in terms of the quality of care at each health facility. R10. Commission an assessment of primary health care challenges to identify areas that can be improved with digital health mechanisms. To be effective and impactful, digital health interventions or applications should respond directly to primary care challenges that can be identified through assessments like the World Bank’s vital signs profile for primary health care performance improvement (PHCPI). 23 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES R11. Commission a data quality assessment. As part of the effort to strengthen surveillance and data collection, the World Bank is currently conducting a process mining analysis, from data collection to data reporting and analysis. This can contribute to a larger assessment of data quality across the health care sector. Roadmap of Actions START NOW START NEXT START LATER R9. Train data capturers on data R9. Provide ongoing mentorship data R9. Provide accreditation to health management and mandate data management at national and care institutions that comply with use certifications for managers as subnational levels the Digital Health Standard a mandatory requirement . Conduct routine data quality Operating Procedures R10. Conduct primary health care reviews quarterly R10. Develop an application/platform for (PHC) performance measurement R11. Provide in-service training to e-learning assessment to discover new health care workers using e- healthy system challenges learning and digital resources) R11. Commission a data quality assessment to improve data quality at the source DIGITAL HEALTH DIMENSION 4: APPLICATIONS Strategic Outcome 4 Reduce “pilotitis” and fragmentation of interventions. As mentioned in the situational analysis, some digital health intervention pilots are being conducted in the country. However, these are not necessarily guided or coordinated by the MoH nor is their management transferred to it. In addition, they may not always respond to the urgent needs and objectives set by the government. A limited electronic health records (EHR) complicates efforts to trace patients within a facility, across facilities, or over time. Typically, an HMIS digitizes health data at the district level and does not include patient-level EHR. Moreover, unique identifiers for patients do not exist or are not used, adding to the challenge of tracing patients through the system, from one facility to another, or over time. The development of patient-centered applications is a vital consideration to improve the patient journey in seeking and accessing health care and enhance patient empowerment. The COVID-19 pandemic exposed the importance and relevance of digital health solutions to improve and overcome some of the persistent challenges of primary care and the need to accelerate the development of simple digital health applications that respond to end users’ needs. Recommendations R12. Design a prioritized and costed plan for digital health applications. This plan should determine which interventions are relevant, provide an estimate of costs and benefits, assign responsible parties, and provide a clear monitoring and evaluation plan. The WHO Digital implementation investment guide (DIIG) could be a useful resource to guide this work. 24 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP Based on R12, the following is an initial list of digital health applications or interventions recommended for scale up in the short-, medium-, and long term. These interventions have been proposed based on the current primary health care challenges facing Lesotho and could offer immediate and measurable impact. Appendix H connects these applications to specific health system challenges and classifies them according to the WHO Classification of Digital Health Interventions. SHORT TERM PRIORITY: MEDIUM/HIGH LEVEL OF EFFORT: LOW Rapid implementation, minimal effort, ability to leverage the current infrastructure and technology in Lesotho RECOMMENDATION END USER SMS technologies for automatic appointment scheduling, appointment reminders (for  Patient priority diseases) and notification of non-sensitive lab-test results (e.g., COVID negative results). Health promotion messaging through SMS, WhatsApp, or other digital means or  Patient social platforms for preventive care and public health topics to increase awareness and self-management Operationalize and digitalize feedback mechanism through SMS such as the World Bank-supported Citizen Feedback Mechanism Incorporate all Village Healthcare Workers data capturing tools into Bophelo ka  Health care provider Mosebeletsi App and workers Patient portal for education, access to patient information, two-way communication  Patients  Health care provider  Data services Disease outbreak notifications, early warning applications, emergency health  Health care provider preparedness and resilience using geospatial data and notification by SMS or IVR  Patients technology Implementation of intelligent, interactive, and user-friendly dashboards at the national,  Data services district, and health facility levels (where computers are available). Central intelligence dashboards that capture patterns and clusters for timely national pandemic response and action. While this intervention is easy to develop, its effectiveness depends on the quality of data and the capacity to collect data at a more granular level. Rule-based system development in health information systems (HIS) and EMR to  Data services control the integrity and quality of data entry Expansion of e-Register to mobile devices to allow real-time access to community-  Data services level data (instead of month-long wait times) to inform programming, progress, early diagnosis, and early intervention MEDIUM TERM PRIORITY: MEDIUM LEVEL OF EFFORT: HIGH Needed in the short-to-medium term, but for which development depends on different enablers, such as data quality, connectivity and electricity, hardware (computers and tablets), and digital skills RECOMMENDATION END USER Telemedicine and telecare services to facilitate access in remote areas. Initially,  Patients telemedicine efforts can be focused on following up on treatment of HIV and TB patients. Expansion and implementation (beyond the pilot stage) of tele mentoring programs to  Health care support health care workers at health facilities and village health care workers, as well providers and as for task shifting workers Continued on next page 25 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Continued from previous page RECOMMENDATION END USER Implementation of referral systems to support the transfer and reference of patient  Health care information across facilities and networks, without the need for the BOKANA (patient providers and booklet) workers Automated and paperless administrative and clinical management processes  Health care providers and workers Interfacing with hospitals’ management systems to improve efficiency  Patients  Health care providers LONG TERM PRIORITY: HIGH LEVEL OF EFFORT: HIGH Critical interventions, but which require foundational elements and complex development approaches that cannot be implemented in the short term RECOMMENDATION END USER Expansion of the e-Register to include programs to improve quality and continuity of  Health care care. The e-Register currently includes only HIV and TB patients and additional cross- providers and cutting programs workers  Health care Automatic Medical Triage applications based on similar cases providers and workers R13. Commission technical assistance to support public-private partnerships (PPP) and service level agreements (SLA) for digital health interventions. This should be accompanied by a mid-term strategy to create skilled, in-house resources. Coordination with WHO and IFC could support this activity. R14. Design a plan to scale up e-Register gradually over the next three years to transform all existing health programs and into a comprehensive EMR. Expand e-Register to include aspects such as family planning, chronic diseases, children’s health, among others to assure comprehensive care for all. R15. Establish an innovation testing environment for the various interventions and evaluate impact and feasibility. Testing environments, such as an innovation and regulatory sandbox or living lab, can provide a framework to test solutions in a responsible, monitored, and real-world environment. With flexible regulations, these environments can generate evidence, measure social response, eliminate failed interventions, and reduce future implementation costs. The National University of Lesotho is developing innovation hubs that could be useful for integration. R16. Commission feasibility and economic evaluation studies of priority digital health interventions. Build evidence on the cost-effectiveness and cost benefit of digital health interventions such as eRegister, DHIS-2, ECHO to prioritize future investment. 26 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP Roadmap of Actions START NOW START NEXT START LATER R12. Include digital health in annual R12. Improve digitalization of health R12. Roll out HRIS to all District Health budget allocations for 2024- workers’ records and the Management Teams (DHMT) 2028 remuneration system by R16. Commission evaluation studies R12. Select and implement the best customizing and implementing (R16) solution for an Open Health Human Resources Information Information Exchange Systems (HRIS) R14. Expand the e-Register to other R12. Train users in IHRIS and pilot the health programs system R13/15. Assess PPP opportunities to expand potential digital health interventions Based on the most urgent health system challenges, the MOH should prioritize the following areas over the next five years: Foundational Investments  Structural and governance changes at the MoH to promote digital health (R1, R4, R5, R7)  Assessment, planning, and investment in infrastructure enablers such as connectivity, electricity, and data hosting (R2, R6, R8)  Development of digital health skills within the MoH system through collaboration with university programs (R3) Functional Investments  Scale-up of e-Register toward development of a comprehensive electronic medical record system, along with strengthening of the digital health platform to connect other information systems (R7, R14)  Implementation of processes to improve data collection, reporting, and use, enabling insight into systems, provide evidence base public health and strengthening public health surveillance (R9, R10, R11)  Scale-up of current digital health applications and prioritization of the implementation of SMS and mobile technology to enhance service delivery through automatic scheduling, referral, and health promotion (R12, R13, R16) Frontier Investments  Investment in innovative digital health solutions and incorporation of effective assessment mechanisms (R15) 27 This page is for collation purposes SECTION 5 CONCLUSION E mploying a comprehensive analysis using interviews and desk reviews, this joint report between the MoH of Lesotho and the World Bank summarizes the current maturity of digital health in Lesotho and provides a comprehensive view of the digital health landscape that could support the transformation of primary care and redesign service provision. By identifying strengths, weaknesses, opportunities and threats, the report aims to position Lesotho to continue its digital health journey to improve health care service delivery. The report took in consideration the extensive work done by different partners in Lesotho to reach a comprehensive conclusion and to set a maturity score for the country. The country’s infrastructure, mobile coverage, and extensive utilization of information health systems create a sound baseline to launch this evolution and increase awareness of digital health. However, there is a risk that the opportunity to leap forward in digital health transformation will be lost without solid commitment and ownership of a clear strategy as well as a roadmap for the implementation of digital health interventions and support for alignment with current initiatives. The COVID-19 pandemic exposed the importance and relevance of digital health solutions to improve and overcome persistent challenges facing primary care. Most current digital health interventions in Lesotho are related to health information systems, such as Logistic Management Information Systems (LMIS) or DHIS-2 for reporting, and a limited EMR system (e-Register) that covers only HIV- and TB-related programs. However, to reduce inequity and provide comprehensive care, it is necessary to integrate and empower patients in the digital transformation. For this purpose, awareness of the importance of digital health, structural changes in the governance apparatus, and the diffusion and communication of the benefits of digital health are critical to overcome reluctance to change. This report is a call to action to upgrade the current eHealth strategy to a comprehensive digital health strategy with priority interventions, a costed implementation plan, and provisions for future impact assessment, geared toward delivering better health in a digital world. 29 REFERENCES Adepoju P. (2020). “Africa turns to telemedicine to close mental health gap.” The Lancet. Digital health, 2(11), e571–e572. https://doi.org/10.1016/S2589-7500(20)30252-1 AU (African Union). 2015.”Agenda 2063”. https://au.int/en/agenda2063/overview AU (African Union). 2020. “The Digital Transformation Strategy for Africa (2020-2030). https://au.int/en/documents/20200518/digital-transformation-strategy-africa-2020-2030 Henry, Tanya, 2020. “After COVID-19, $250 billion in care could shift to telehealth”.< https://www.ama-assn.org/practice-management/digital/after-covid-19-250-billion-care- could-shift-telehealth>. Holst, Christine, et al. 2020. “Sub-Saharan Africa—the new breeding ground for global digital health.” The Lancet Digital Health, Volume 2 (4): e160-e162. doi: 10.1016/S2589- 7500(20)30027-3. ITU (International Telecommunications Union).ITU ICT Eye https://www.itu.int/net4/itu- d/icteye Kabir MH and Kibria M. 2021. “HIS Mapping: An Inventory of Digital Tools in Use by the MoH and Family Welfare in Bangladesh.” https://www.data4impactproject.org/publications/his-mapping-an-inventory-of-digital-tools- in-use-by-the-ministry-of-health-and-family-welfare-in-bangladesh.D4I, USAID >. McKinsey & Company. 2021. “How the medtech industry can capture value from digital health” https://www.mckinsey.com/industries/life-sciences/our-insights/how-the-medtech-industry- can-capture-value-from-digital-health Measure EVALUATION. “Lesotho: HIS Indicators” https://www.measureevaluation.org/his- strengthening-resource-center/country-profiles/lesotho Millennium Challenge Corporation Ministry of Health. 2017. “Electronic Medical Records (EMR) Assessment: Preliminary assessment report.” Kingdom of Lesotho Ministry of Health. 2018. “HMIS Strategic Plan 2018-2022”. Kingdom of Lesotho Ministry of Health. 2018. “National eHealth Strategy 2019-2023”. Kingdom of Lesotho. Ministry of Health. “Report of Rapid Assessment of the Health management Information System in Lesotho..” Kingdom of Lesotho. Draft Report Mwase, Takondwa et al. 2010. “Lesotho Health Systems Assessment 2010”. Bethesda, MD: Health Systems 20/20, Abt Associates Inc. National Department of Health, South Africa. ,2018 “National Digital Health Strategy for South Africa 2019-2024.” National Department of Health https://www.health.gov.za/wp- content/uploads/2020/11/national-digital-strategy-for-south-africa-2019-2024-b.pdf SADC (Southern Africa Development Community). 1999. “Protocol on Health”. http://www.sadc.int/files/7413/5292/8365/Protocol_on_Health1999.pdf. 30 FORWARD: STRATEGIC RECOMMENDATIONS AND IMPLEMENTATION ROAD MAP UNAIDS (Joint United Nations Programme on HIV/AIDS). 2020. “Health Situation room Evaluation”. UNAIDS Evaluation Office. https://www.unaids.org/en/resources/documents/2021/Health- situation-room-evaluation-report UNICEF (United Nations Children's Fund). 2018. “Data Requirements Analysis and data mapping”. — Lesotho. https://developmentgateway.org/wp- content/uploads/2020/08/UNICEF_Lesotho_Diagnostic.pdf USAID (United States Agency for International Development). “East Africa digital health initiative roadmap” https://www.usaid.gov/sites/default/files/documents/1864/Digital- REACH-Initiative-factsheet_508.pdf UN (United Nations).2015. “Transforming our world: the 2030 Agenda for Sustainable Development” https://sdgs.un.org/2030agenda Vodafone. 2020. “Vodafone Foundation to expand Ambulance Taxi programme in Africa”. https://www.vodafone.com/news/press-release/vodafone-foundation-ambulance-taxi- programme-in-africa WHO (World Health Organization). 2017. “Joint External Evaluation of IHR Core Capacities of the Kingdom of Lesotho”. World Health Organization, Geneva. WHO (World Health Organization).2021. “FRAMEWORK FOR IMPLEMENTING THE GLOBAL STRATEGY ON DIGITAL HEALTH IN THE WHO AFRICAN REGION” https://www.afro.who.int/sites/default/files/2021-07/AFR-RC71 — 2012. “National eHealth Strategy Toolkit” https://www.who.int/ehealth/publications/overview.pdf — “Classification of digital health interventions.” Geneva: World Health Organization; 2018 (WHO/RHR/18.06). Licence: CC BY-NC-SA 3.0 IGO — Global Observatory of eHealth < https://www.who.int/observatories/global-observatory-for- ehealth — 2021. “Global strategy on digital health 2020-2025”. Geneva: World Health Organization; Licence: CC BY-NC-SA 3.0 IGO. — Score for Health Data Technical Package (SCORE) World Bank Group. 2019. “South Africa Digital Economy Diagnostic”. Washington, DC: World Bank. License: Creative Commons Attribution CC BY 3.0 IGO — 2021. “Who needs what where: Targeting Policies and Interventions to Accelerate Human Capital Formation for Adolescents in Lesotho”. Washington DC: World Bank. License: Creative Commons Attribution CC BY 4.0 — 2021. “Digital Economy for Africa (DE4A) flagship initiative”. https://www.worldbank.org/en/programs/all-africa-digital-transformation# 31 This page is for collation purposes GLOSSARY (According to the WHO Global Strategy on Digital Health 2020‒2025)13 Artificial An area of computer science that emphasizes the simulation of human intelligence intelligence processes by machines that work and react like human beings Big data The emerging use of rapidly collected, complex data in such unprecedented quantities that terabytes (1012 bytes), petabytes (1015 bytes) or even zettabytes (1021 bytes) of storage may be required. The unique properties of big data are defined by four dimensions: volume, velocity, variety, and veracity. As more information is accruing at an accelerating pace, both volume and velocity are increasing. Digital divide Refers to the gap between demographics and regions that have access to modern information and communications technology and those that do not or have restricted access. This technology can include the telephone, television, personal computers, and the Internet. Digital health The field of knowledge and practice associated with the development and use of digital technologies to improve health. Digital health expands the concept of eHealth to include digital consumers, with a wider range of smart-devices and connected equipment. It also encompasses other uses of digital technologies for health such as the Internet of things, artificial intelligence, big data, and robotics. eHealth The cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health care services, health surveillance, health literature, and health education, knowledge, and research. Health data The systematic application of information and communications technologies, computer science, and data to support informed decision making by individuals, the health workforce, and health systems, to strengthen resilience to disease and improve health and wellness. It includes all data pertaining to the health status of a data subject which reveal information relating to the past, current or future physical or mental health status of the data subject. This includes information about the natural person collected during registration for, or the provision of, health care services to that natural person; a number, symbol or assigned to a natural person to uniquely identify the natural person for health purposes. Glossary continued on next page 13 World Health Organization (2021). 33 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Glossary continued from previous page Health A system that integrates data collection, processing, reporting, and information use of the information necessary for improving health service system effectiveness and efficiency through better management at all levels of health services. Internet of A system of interrelated computing devices, mechanical and digital things machines, objects, animals, or people that are provided with unique identifiers and the ability to transfer data over a network without requiring human-to-human or human-to computer interaction. Interoperability The ability of different applications to access, exchange, integrate and cooperatively use data in a coordinated manner using shared application interfaces and standards, within and across organizational, regional, and national boundaries, to provide timely and seamless portability of information and optimize health outcomes. Multistakeholder These include, but are not limited to, intergovernmental and groups international organizations; non-State actors such as nongovernmental and civil society organizations, donors and aid agencies, foundations and development banks; universities and research institutions; faith- based organizations, health insurance groups and other health-care funders; the private sector; technology developers; and the health care community in particular health care providers and health care professionals, patients and the public. Telemedicine The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health care workers, with the aim of advancing the health of individuals and communities. 34 APPENDICES APPENDIX A ASSESSMENT METHODOLOGY The assessment was conducted using a maturity model methodology. In general, maturity models focus on people, processes, technology, and organizational capabilities to help understand current conditions and determine a future goal. Low maturity levels show an opportunity for investment, while higher maturity levels illustrate a greater probability of success for disruptive interventions. To collaborate with other donors and organizations and reduce fragmentation, the assessment integrated and combined different digital health assessment tools and indicators into one digital health assessment toolkit—a hybrid approach that can be used to complete other tools or source input using different mechanisms: 1. Digital health landscape profile: A set of quantitative indicators including basic sociodemographic information, coverage of information and communication technologies (ICT), types of digital health interventions, and quantitative information on exposure to digital health within the workforce 2. Digital health maturity score and questionnaire: A maturity score framework was built that analyzes the maturity of digital health across four areas: Digital Environment, Architecture and Data, Applications, and Analytics. Within each area, several indicators are presented (75 in total) that explore topics such as leadership and governance, strategy and investment, legislation, policy and compliance, workforce, standards and interoperability, infrastructure, and services. The indicators are extracted from the following digital assessment tools and then mapped within the scoring tool: Global Digital Health Index University of Chicago Data Framework Measure Evaluation HIS Framework USAID Digital Health Investment Review Tool Global Observatory of eHealth Broadband Commission WHO/ITU eHealth Strategy Toolkit IS4H Maturity Assessment tool University of Oxford Cybersecurity Capacity Maturity Model 3. In-depth interviews and desk review: This mechanism aims to collect primary and secondary source information to understand some of the topics covered in more depth. In addition, this mechanism will be used to discuss the results, establish the maturity 35 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES level, and generate input for a future digital health roadmap strategy and interventions. A total of 16 interviews were conducted online in English using a purposive sample composed of stakeholders from the MoH and other health care providers, partners, organizations, and academia. The content was analyzed by identifying and extracting topics such as maturity, enablers, barriers and challenges, strategy, applications, and data. Relevant subtopics were then identified and mapped to the four dimensions of the digital health assessment. 36 APPENDIX B MAIN DIAGNOSTICS AND MOST RELEVANT RECOMMENDATIONS FROM PREVIOUS ASSESSMENTS CONDUCTED IN LESOTHO Appendix table B.1 Diagnostics and recommendations from previous assessments ASSESSMENT DIAGNOSTIC MOST RELEVANT RECOMMENDATIONS 1. USAID/MCC/RTI  No official eHealth strategy approved, different plans are out of date, ICT  Facilitate the launching of the eHealth Strategy and fast-track the launch Lesotho ICT department current structure is not supportive  Coordination and partnership framework to align initiatives Assessment of the  Lack of coordination and alignment between MOH and implementing Health Sector (2020)  Form a unit to develop Standard Operations Procedures partners  Re-structure the ICT department to have a Director of ICT and expand training  Lack of financial resources to cover ICT requirements opportunities  Out of date systems and hardware  Update the ICT infrastructure  Limited number of Standard Operating procedures  Increase data supply in DHIS-2 37  No data sharing policy  Work with MoH and HFs to develop a health indicator guide that indicates  There is limited use of DHIS2 data visualization and report development what data are collected at each tier of the health system modules at the subnational level. Also limited understanding of data  Strengthen DHIS-2 architecture, indicators and ICT infrastructure to enable collection by health workers at various levels better connectivity  Duplication of systems and existent fragmentation  More-focused requirements gathering should be pursued to determine that  Longitudinal patient data viewing and graphing functions are nonexistent in eRegister can work its way toward covering a range of disease conditions. eRegister There are a strong desire and need to evolve the eRegister into an EHR.  Limited functionalities within eRegister and few programs covered Include reminders and notifications  Limited interoperability across information systems  Greater flexibility should be offered for data analysis of patient data by allowing graphing and charting of some patient data  Most respondents appreciate the importance of data, although some complained that data recording added more work for them. Great  Increase interoperability across systems (DHIS-2, eRegister, DISA) disappointment was expressed concerning the lack of visible usage and  Need for pre-service and in-service training on digital health, ICT and action of the data by management information systems  Limited training  Digitalize most of the process taking care of data quality  Large number of paper-based registries that increases manual workload APPENDICES Table continued on page 38 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table B.1 Diagnostics and recommendations from previous assessments (continued) ASSESSMENT DIAGNOSTIC MOST RELEVANT RECOMMENDATIONS 2. MOH/ICAP EMR The system was designed:  Move to open source and web based Assessment (2017)  without much interoperability with other systems  MOH should take ownership of the design and customization  without a user-centered design  Include open-standards  with limited functionality  Discourage the local server approach  non-functional interfaces  Strengthen the user technical support  no skill transfers  Engage stakeholders in the development of the application  no technical support  no system roles defined The results: Physicians returned to manual work and the system was withdrawn 3. HMIS Strategic Plan  Existence of a central HMIS unit with capacity in core health information  A review of HMIS policies and guidelines, including the development of a (2018‒2022) sciences to meet the national health information needs national indicator data set and streamlining of data collection tools to produce  An existing relatively robust public internet network provides an opportunity information which will inform policy and improve programs to build a single integrated web-based health data warehouse  Urgent need to integrate current parallel and fragmented information systems 38  While HMIS policies and plans were in place, they failed to address through establishment of a user-friendly data warehouse that supports strategic information coordination mechanisms and one agreed upon interoperability with electronic medical records (EMR) and other data sources national indicator dataset  Systems that promote data quality checks and analytics, data display  Data management practices which constrain information dissemination information dissemination capability accessible to users across all levels of the and use compounded -further by gaps in human resources capacity for health system, enhance the use of quality information to inform planning, HMIS resource allocation and monitoring of program implementation and to support optimization of the EMR system to generate routine MOH reports  While some information systems exist at district level, there are no HMIS organizational structure and reporting lines/linkages;  Innovative strategies to build human resource capacity for data management and use at national, district and facility level  Human resource capacity in data management and information systems support is limited  Existence of parallel reporting lines with a hybrid of paper and electronic systems Table continued on page 39 Appendix table B.1 Diagnostics and recommendations from previous assessments (continued) ASSESSMENT DIAGNOSTIC MOST RELEVANT RECOMMENDATIONS 3. HMIS Strategic Plan Several gaps and challenges were observed at the six hospitals where EMR (2018‒2022) was implemented, including inadequate use of the system by clinicians and pharmacists. This is partly due to system design issues, user competency and lack of user motivation, lack of infrastructure, integration with other systems and generation of accurate routine and need based reports. 4. UNICEF Lesotho Data  Data demand and culture for data is limited due to lack of leadership and  National results framework to measure progress will incentive the use of data Requirement Analysis political turnover, policy compliance, delayed implementation of policies  Explore mechanisms for sustaining Statistician roles at ministries and Data Mapping that would generate priority data (2018)  Advocate Government of Lesotho to make data visualization tools available to  Focus on data collection and not interpretation and use the public (i.e., making some access to the Health Situation Room)  Health sector has a robust data supply systems and collection methods,  Support the development microdata sharing policies and national data but lack on indicators of quality management policies  However, data access is complex, no standards or protocols to share  Explore potential engagement with partners to leverage and scale up microdata information systems and systems like eRegister  Gap between data demands from users (donors) and data supply. This is  Expanding the capabilities for GIS data analysis less of a challenge in the healthcare sector  Support the utilization of mobile devices for data collection (i.e., tablets)  More disaggregation of data is needed 39  Encourage linkages between NICR and administrative data systems  Delays in data delivery. Data may be located in local servers instead of centralized database  Data quality and capacity for good data collection are also challenges  Lack of online dissemination 5. USAID/MCC/SBC4D  Infrastructure and technology maturity are not a barrier for the wide  Better integration of data systems and improvement of data flows between the Statistical Capacity use of ICT different stakeholders with the inclusion of Village Health Workers in the and Data Use in  Implementation of data policies is being challenged by a lack of leadership process Lesotho (2020) and leadership support  More granular data analysis is needed to support decision and policymaking.  Limited demand of advanced skills and data science skills; however basic This needs to be strengthened by the development of advanced data science ICT skills are present skills Table continued on page 40 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table B.1 Diagnostics and recommendations from previous assessments (continued) ASSESSMENT DIAGNOSTIC MOST RELEVANT RECOMMENDATIONS 5. USAID/MCC/SBC4D  Data is not being used for policymaking  Increase data access to other non-government actors and vice-versa to Statistical Capacity  There is a lack of offer and demand of data, with both affecting the support health policies and Data Use in development of the other  Improvement of gender-data practices Lesotho (2020) 6. World Bank Lesotho’s  Potential is still very much underutilized. Lesotho has been able to expand Priority 1: Improve the enabling environment for the digital economy Digital Economy access to digital infrastructure and services, but domestic demand remains  guide the deployment of digital infrastructure deployment and bridge the digital Diagnostic (2020) modest divide  Digital potential is not being reached due to the current fragmentation lack  Improve the legal and regulatory environment by addressing identified gaps in of coordination and capacity hamper the government’s efforts in the legislation, with immediate priority given to passing the bills on cybersecurity implementation of digital government platforms and e-transactions  Digital skills constitute a clear bottleneck for Lesotho and an area where Priority 2: Drive digital transformation and demand by strengthening public sector policy and institutional reforms are needed platforms and Infrastructure  Private digital platforms have not yet found a proper footing in Lesotho and  deepen the approaches to digitization in the identified sectoral and thematic very few locally developed platform-based, business models exist priority areas  Ensuring that government has the necessary infrastructure and connectivity and that these are widely used 40  Increasing interoperability between platforms for increased efficiency and service delivery by leveraging experiences from the national identity system and enhancing the digital payment infrastructure  Developing citizen-facing digital public services to drive demand, access, and efficiencies Priority 3: Strengthen the digital ecosystem through digital skills and entrepreneurship  Developing a strategy and defining the implementation mechanisms for digital skills development in Lesotho  Improving digital infrastructure and connectivity in research and educational institutions by establishing a National Research and Education Network in Lesotho  Improve the coordination and implementation of the digital entrepreneurship agenda APPENDIX C DETAILED SCORING FOR LESOTHO Appendix table C.1 Indicators of Digital Maturity in Lesotho A. DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE DIGITAL HEALTH ENVIRONMENT (TOTAL SCORE) 1.48 the following indicators focus on the macro level of digital health in terms of strategy, guidelines, curriculum, and prioritization LEADERSHIP AND GOVERNANCE 1.7 01 DIGITAL HEALTH PRIORITIZED AT THE NATIONAL LEVEL THROUGH DEDICATED BODIES / MECHANISMS FOR GOVERNANCE Global Digital Does the country have a separate department / agency / national working group for digital health? 2.0 Health Index No coordinating body exists and/or nascent governance structure for digital health is constituted on a case-by-case basis 1.0 Governance structure is formally constituted though not fully functional or meeting regularly 2.0 Governance structure and any related working groups have a scope of work (SOW) and conduct regular meetings with stakeholder participation 3.0 and/or consultation Governance structure is fully functional, government-led, consults with other ministries, and monitors implementation of digital health based on a 4.0 work plan The digital health governance structure is institutionalized, consults with other ministries, and monitors implementation of digital health. It is 41 relatively protected from interference or organizational changes. It is nationally recognized as the lead for digital health. The governance structure 5.0 and its technical working groups emphasize gender balance in membership 02 DIGITAL HEALTH PRIORITIZED AT THE NATIONAL LEVEL THROUGH PLANNING Global Digital Is digital health included and budgeted for in national health or relevant national strategies and/or plan(s)? 2.0 Health Index The focus of this indicator is on the inclusion of digital health or eHealth in the national health strategy Digital health is not included in the national health strategy. It is being implemented in an ad-hoc fashion in health programs 1.0 There is some discussion of inclusion of digital health in national health or other relevant national strategies or plans. Proposed language for 2.0 inclusion of digital health in national health or relevant national strategies and/or plans has been made and is under review Digital health is included in national health or relevant national strategies and/or plans 3.0 Digital health is being implemented as part of national health or other relevant national strategies and/or plans 4.0 Digital health is implemented and periodically evaluated and optimized in national health or other relevant national strategies and/or plans 5.0 Table continued on page 42 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) A. DIGITAL ENVIRONMENT INDICATORS SCORE SOURCE 03 AWARENESS RISING OF CYBERSECURITY University of Oxford - 1.0 The need for awareness of cybersecurity threats and vulnerabilities across the health sector is not recognized or is only at initial stages of discussion Cyber Maturity Model Awareness raising programs, courses, seminars, and online resources are available for target demographics from public, private, academic, 2.0 and/or civil society sources, but no coordination or scaling efforts have been conducted. A national program for cybersecurity awareness raising in health care, led by a designated organization (from any sector) is established, which 3.0 addresses a wide range of demographics and issues, but no metrics for effectiveness have been applied. Metrics for effectiveness are established and evidence of application and lessons learnt are fed into future programs. The evolution of the program is supported by the adaptation of existing materials and resources, involving clear methods for obtaining a measure of suitability and 4.0 quality. Awareness raising programs are adapted in response to performance evidenced by monitoring which results in the redistribution of resources 5.0 and future investments. Metrics contribute toward national cybersecurity strategy revision processes. STRATEGY AND INVESTMENT 1.0 04 NATIONAL EHEALTH/ DIGITAL HEALTH STRATEGY OR FRAMEWORK Global Digital 1.0 Does the country have an eHealth or digital health strategy or framework and a costed digital health plan? Health Index There is no digital health strategy or framework. Draft digital health strategy or framework developed, but not officially reviewed. 1.0 42 National digital health strategy or framework approved. 2.0 National digital health costed plan developed and approved. 3.0 National digital health strategy and costed plan partially implemented with resources to ensure full implementation. 4.0 National digital health strategy and costed plan fully implemented with planning underway for the next 3–5-year cycle. 5.0 05 PUBLIC FUNDING FOR DIGITAL HEALTH Global Digital 1.0 What is the estimated percent (%) of the annual public spending on health committed to digital health? Health Index No budget line item for digital health available. A budget line item for digital health exists but proportion not available. 1.0 Less than 1% 2.0 1‒3% 3.0 3‒5% 4.0 Greater than 5% 5.0 Table continued on page 43 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL ENVIRONMENT INDICATORS SCORE SOURCE 06 HEALTH SYSTEM PLAYERS ARE MAKING USE OF INCENTIVE STRUCTURES, BEYOND TAX BENEFITS TO ALSO INCLUDE INNOVATION Broadband 1.0 PARKS, GRAND CHALLENGES, AND OTHER INITIATIVES, WHILE SYSTEMATICALLY INCORPORATING THEM INTO BUSINESS MODELS Commission - AI No incentives structures exist 1.0 Limited incentives, such as tax benefits, are in place 2.0 Usage remains low due to the technical nature of applying for incentives 3.0 Health system players are making use of incentive structures, e.g., tax benefits, tax immunity, or government grants, and are incorporating these 4.0 into business models Health system players are making use of incentive structures, beyond tax benefits to also include innovation parks, grand challenges, and other 5.0 initiatives, while systematically incorporating them into business models LEGISLATION AND POLICY 1.0 07 LEGAL FRAMEWORK FOR DATA PROTECTION (SECURITY) Global Digital 1.0 Is there a law on data security (storage, transmission, use) that is relevant to digital health? Health Index There is no law on data security (storage, transmission, use) that is relevant to digital health. 1.0 There is a law on data security (storage, transmission, use) that is relevant to digital health that has been proposed and is under review. 2.0 43 There is a law on data security (storage, transmission, use) that is relevant to digital health that has been passed but has not yet been fully 3.0 implemented. There is a law on data security (storage, transmission, use) that is relevant to digital health that has been implemented, but not consistently 4.0 enforced. There is a law on data security (storage, transmission, use) that is relevant to digital health that has been implemented and enforced consistently 5.0 08 LAWS OR REGULATIONS FOR PRIVACY, CONFIDENTIALITY, AND ACCESS TO HEALTH INFORMATION (PRIVACY) Global Digital 1.0 Is there a law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data? Health Index There is no law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data. 1.0 There is a law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data that has been 2.0 proposed and is under review. Table continued on page 44 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE LAWS OR REGULATIONS FOR PRIVACY, CONFIDENTIALITY, AND ACCESS TO HEALTH INFORMATION (PRIVACY) (continued) There is a law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data that has been 3.0 passed, but not yet fully implemented. There is a law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data that has been 4.0 implemented, but not consistently enforced. There is a law to protect individual privacy, governing ownership, access and sharing of individually identifiable digital health data that has been 5.0 implemented and is enforced consistently. 09 CROSS-BORDER DATA SECURITY AND SHARING Global Digital Are protocols, policies, frameworks, or accepted processes in place to support secure cross-border data exchange and storage? This includes health- 1.0 Health Index related data coming into a country, going out of a country, and/or being used in a country related to an individual from another country. There are no protocols, policies, frameworks, or accepted processes in place to support secure cross-border data exchange and storage. 1.0 Protocols, policies, frameworks or accepted processes for cross border data exchange and storage have been proposed and are under review. 2.0 Protocols, policies, frameworks or accepted processes for cross border data exchange and storage have been passed but are not fully 3.0 implemented. 44 Protocols, policies, frameworks or accepted processes for cross border data exchange and storage have been implemented, but not consistently 4.0 enforced. Protocols, policies, frameworks or accepted processes for cross border data exchange and storage have been implemented and enforced 5.0 consistently. 10 TRUST AND CONFIDENCE ON THE INTERNET: University of Oxford - 1.0 USER TRUST AND CONFIDENCE ON THE INTERNET Cyber Maturity Model Most Internet users have blind trust on websites and regarding what they see or receive online. 1.0 A very limited proportion of Internet users critically assess what they see or receive online and believe that they can use the Internet and protect 2.0 themselves online. A growing proportion of Internet users critically assess what they see or receive online, based on identifying possible risks. User-consent policies 3.0 are in place designed to notify practices on the collection, use or disclosure of sensitive personal information. Table continued on page 45 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE TRUST AND CONFIDENCE ON THE INTERNET: USER TRUST AND CONFIDENCE ON THE INTERNET (continued) Most Internet users critically assess what they see or receive online, based on identifying possible risks. Most Internet users feel confident while using the Internet and could recognize non-legitimate websites (including mimicry attempts), and have a sense of control over providing 4.0 personal data online. Individuals assess the risk in using online services, including changes in the technical and cybersecurity environment and continuously adjust their 5.0 behavior based on this assessment. 11 TRUST AND CONFIDENCE ON THE INTERNET: USER TRUST IN E-GOVERNMENT SERVICES 1.0 Government offers no or limited e-services but has not publicly promoted the necessary secure environment. If e-government services are 1.0 provided, users are unfamiliar with or lack trust in them. Government continues to increase e-service provision, but also recognizes the need for the application of security measures to establish trust in these services. The need for security in e-government services is recognized by stakeholders and users. A limited proportion of users trust in the 2.0 secure use of e-government services. E-government services have been fully developed. High-level risks affecting e-government services are prioritized to reduce occurrences. The public sector promotes use of e-government services and trust in these services through a coordinated program, including the compliance to 3.0 web standards that protect the anonymity of users. 45 Public authorities are routinely publishing certain information about their activities. Privacy-by-default is promoted as a tool for transparency in e- 4.0 government services. Most users trust in the secure use of e-government services and make use of them. E-government services and promotion thereof are continuously improved and expanded to enhance transparent/open and secure systems and 5.0 user trust. Impact assessments on data protection in e-government services are consistently taking place and feed back into strategic planning. 12 TRUST AND CONFIDENCE ON THE INTERNET: USER UNDERSTANDING OF PERSONAL INFORMATION PROTECTION ONLINE 1.0 Users and stakeholders within the public and private sectors have no or minimal knowledge about how personal information is handled online, nor do they believe that adequate measures are in place to protect their personal information online. There is no or limited discussion regarding the 1.0 protection of personal information online. Discussions may have begun and involve multiple stakeholders, but no privacy standards are in place. Users and stakeholders within the public and private sectors may have general knowledge about how personal information is handled online; and may employ good (proactive) cybersecurity practices to protect their personal information online. Discussions have begun regarding the protection 2.0 of personal information and about the balance between security and privacy, but this has not resulted in concrete actions or policies. Table continued on page 46 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE TRUST AND CONFIDENCE ON THE INTERNET: USER UNDERSTANDING OF PERSONAL INFORMATION PROTECTION ONLINE (continued) A growing proportion of users have the skills to manage their privacy online, and protect themselves from intrusion, interference, or unwanted access of information by others. There is constant public debate regarding the protection of personal information and about the balance between 3.0 security and privacy, which informs privacy policies within public and private sectors. All stakeholders have the information, confidence, and the ability to take measures to protect their personal information online and to maintain control of the distribution of this information. Users and stakeholders within the public and private sectors widely recognize the importance of 4.0 protection of personal information online and are sensitized to their privacy rights. Mechanisms are in place in private and public sectors to ensure that privacy and security are not competing. Privacy by default as a tool for transparent Users have the knowledge and skills necessary to protect their personal information online, adapting their abilities to the changing risk environment. There is a wide recognition of the need to ensure security and protection of personal information. Policies are in place in private and 5.0 public sectors to ensure that privacy and security are not competing in a changing environment and are informed by user feedback and public debate. Assessments of personal information protection in eservices are regularly conducted and feed back into policy revision. WORKFORCE 1.0 13 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL PRE-SERVICE TRAINING (PRIOR TO DEPLOYMENT): Global Digital IS DIGITAL HEALTH PART OF CURRICULUM FOR HEALTH AND HEALTH-RELATED SUPPORT PROFESSIONALS IN TRAINING, IN 1.0 Health Index GENERAL? 46 There is no digital health curriculum for health professionals as part of pre-service training requirements. 1.0 Digital health curriculum proposed and under review as part of pre-service training requirements. 2.0 Digital health curriculum implementation underway covering an estimated 0‒25% of health professionals in pre-service training. 3.0 Digital health taught in relevant institutions with an estimated 50‒75% health professionals receiving pre-service training. 4.0 Digital health taught in relevant institutions with >75% of health professionals receiving pre-service training. 5.0 14 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL PRE-SERVICE TRAINING (PRIOR TO DEPLOYMENT): Global Digital 1.0 SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR DOCTORS/PHYSICIANS IN MEDICAL TRAINING? Health Index There is no digital health curriculum for doctors/physicians as part of pre-service training requirements. 1.0 Digital health curriculum proposed and under review as part of pre-service training requirements for doctors/physicians. 2.0 Table continued on page 47 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL PRE-SERVICE TRAINING (PRIOR TO DEPLOYMENT): IS DIGITAL HEALTH PART OF CURRICULUM FOR HEALTH AND HEALTH-RELATED SUPPORT PROFESSIONALS IN TRAINING, IN GENERAL? (continued) Digital health curriculum implementation underway covering an estimated 0‒25% doctors/physicians in pre-service training. 3.0 Digital health taught in relevant institutions with an estimated 50‒75% of doctors/physicians receiving pre-service training. 4.0 Digital health taught in relevant institutions with >75% of doctors/physicians receiving pre-service training. 5.0 15 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL PRE-SERVICE TRAINING (PRIOR TO DEPLOYMENT): Global Digital 1.0 SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR NURSES IN PRE-SERVICE TRAINING? Health Index There is no digital health curriculum for nurses as part of pre-service training requirements. 1.0 Digital health curriculum proposed and under review as part of pre-service training requirements for nurses. 2.0 Digital health curriculum implementation underway covering an estimated 0‒25% or health professionals in pre-service training. 3.0 Digital health taught in relevant institutions with an estimated 50‒75% of nurses receiving pre-service training. 4.0 Digital health taught in relevant institutions with >75% of nurses receiving pre-service training. 5.0 47 16 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL PRE-SERVICE TRAINING (PRIOR TO DEPLOYMENT): Global Digital SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR HEALTH AND HEALTH-RELATED SUPPORT PROFESSIONALS IN 1.0 Health Index TRAINING FOR COMMUNITY HEALTH WORKERS? There is no digital health curriculum for health professionals as part of pre-service training requirements for community health workers. 1.0 Digital health curriculum proposed and under review as part of pre-service training requirements for community health workers. 2.0 Digital health curriculum implementation underway covering an estimated 0‒25% of community health workers in pre-service training. 3.0 Digital health taught in relevant institutions with an estimated 50-75% of community health workers receiving pre-service training. 4.0 Digital health taught in relevant institutions with >75% of community health workers receiving pre-service training. 5.0 17 MATURITY OF PUBLIC SECTOR DIGITAL HEALTH PROFESSIONAL CAREERS Global Digital 1.0 Are there public sector professional titles and career paths in digital health? Health Index No workforce strategy, policy, or guide that recognizes digital health is in place. Distribution of digital health workforce is ad hoc. 1.0 A national needs assessment shows the number and types of skills needed to support digital health with an explicit focus on training cadres of 2.0 female health workers. APPENDICES Table continued on page 48 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE MATURITY OF PUBLIC SECTOR DIGITAL HEALTH PROFESSIONAL CAREERS (continued) Digital health staff roles and responsibilities are mapped to the government's workforce and career schemes and 25‒50% of needed public sector 3.0 digital health workforce in place. An HR policy and strategic plan exists that identifies skills and functions needed to support digital health with an explicit focus on training cadres of 4.0 female health workers and an estimated 50‒75% of public sector digital health workforce in place. A long-term plan is in place to grow and sustain staff with the skills needed to sustain digital health at national and subnational levels with an explicit focus on training cadres of female health workers with an estimated >75% of positions needed filled. Performance management systems 5.0 are in place to ensure growth and sustainability of the digital health workforce with sufficient supply to meet digital health needs and little staff turnover. STANDARDS AND INTEROPERABILITY INFRASTRUCTURE 2.5 18 NETWORK READINESS Global Digital 1.0 Extract the WEF network readiness index score Health Index 1.0‒3.3 1.0 48 >3.3‒4.0 2.0 >4.0‒5.0 3.0 >5.0‒5.4 4.0 >5.4‒7.0 5.0 19 HOW MUCH INTERNET COVERAGE DOES THE COUNTRY HAVE? 5.0 World Bank 0‒20% 1.0 20‒40% 2.0 40‒60% 3.0 60‒80% 4.0. 80‒100% 50 Table continued on page 49 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) DIGITAL HEALTH ENVIRONMENT INDICATORS SCORE SOURCE 20 WHAT TYPE OF MOBILE BROADBAND HAS THE COUNTRY? 4.0 World Bank None 1.0 2G 2.0 3G 3.0 4G 4.0 5G 5.0 21 SERVICES AND APPLICATIONS Global Digital 2.0 Nationally scaled digital health systems Health Index Public sector priorities (e.g., 14 domains included in ISO TR 14639) are supported by nationally scaled digital health systems. (Use separate worksheet to determine the country's specified priority areas, whether digital systems are in place, and whether those systems are national.) [e.g., 2.0 Country X chooses 4 priority areas, uses digital systems to address 2 of the 4, with only 1 being at national scale, receives a score of 25%.] National priority areas are not supported by digital health at any scale. 1.0 Few national priority areas are supported by digital health, and implementation initiated (< 25% priority areas). 2.0 49 Some national priority areas supported by scaled digital health systems (25‒50% of priority areas). 3.0. The majority, but not all national priority areas (50‒75% of priority areas) supported by scaled digital health systems. 4.0 All nationally prioritized areas supported by national-scale digital health systems (>75%) with monitoring and evaluation systems and results. 5.0 Table continued on page 50 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) B. ARCHITECTURE AND DATA ARCHITECTURE AND DATA INDICATORS SCORE SOURCE ARCHITECTURE AND DATA (TOTAL SCORE) The following indicators refer to topics such as interoperability, data governance, health information system infrastructure, knowledge in health 1.96 information systems. LEADERSHIP AND GOVERNANCE 0.7 22 GOVERNANCE STRUCTURE FOR HIS Definition: The exercise of technical, political, and administrative authority to manage national HIS 1.0 HIS Framework affairs at all levels of a country’s health system Evolving governing body for health information systems (HIS) is constituted on a case-by-case basis OR no governing body exists 1.0 An HIS governing body is formally constituted. The governing body has a scope of work that includes the people responsible for data governance oversight. The governing body oversees interoperability directly or 2.0 through a separate technical working group (TWG) The HIS governing body conducts regular meetings with stakeholder participation. 3.0 The HIS governing body uses a work plan (or another tool) to monitor the implementation of HIS interoperability. The HIS governing body is 4.0 government-led HIS governing body mobilizes resources (financial, human resources, and political) to accomplish its goals. 50 HIS governing body is legally protected from interference or organizational changes. The HIS governing body and its TWGs are nationally recognized as the lead for HIS interoperability. The governing body works in liaison with other similar working groups regionally and/or around the 5.0 world. 23 ARE THE POLICIES IN PLACE AROUND GOVERNANCE OF BIG DATA IN HEALTHCARE? 1.0 World Bank Big Data is not included in the national health strategy. It is being implemented in an ad hoc fashion in health programs. 1.0 There is some discussion of inclusion of big data in national health or other relevant national strategies or plans. 2.0 Big Data is included in national health or relevant national strategies and/or plans. 3.0 Big Data is being implemented as part of national health or other relevant national strategies and/or plans. 4.0 Big Data is implemented and periodically evaluated and optimized in national health or other relevant national strategies and/or plans. 5.0 STRATEGY AND INVESTMENT 24 LEGISLATION AND POLICY University of 2.0 Are policies in place around who can use data, how they can use data, which parts can they use, and for what purposes? Chicago No policies exist around use, transfer, and sharing of data 1.0 Table continued on page 51 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE LEGISLATION AND POLICY (continued) The government/Ministry of Health/health organization has policies in place for the use, transfer, and sharing of data but it does not cover all data 2.0 that exists within the organization The government/Ministry of Health/health organization has policies in place for the use, transfer, and sharing of data internally 4.0 The government/Ministry of Health/health organization has policies in place for the use, transfer, and sharing of data internally and externally 5.0 25 PRIVACY AND DATA SECURITY Digital Health Digital health projects may deal with sensitive medical information and clients have a right to have their information managed responsibly. Fear of loss 2.0 Investment Review of privacy may be a barrier to use of a system or accessing services. Security breaches can be damaging for governments and negatively impact the Tool public’s confidence. Describe how privacy and data security will be addressed No mention of privacy or security of data. 1.0 Partially or generically discusses privacy and security approaches to be used. 2.0 Mentions nationally and internationally relevant security policies and partially or generically discusses how security will be implemented. 3.0 Fully describes relevant policies as well as front-end security, back-end security, encryption, and physical security 4.0 Fully describes relevant policies as well as front-end security, back-end security, encryption, and physical security. Includes plan to audit security 51 5.0 as routine maintenance function. 26 ARE THERE POLICIES ON DATA MANAGEMENT, QUALITY OF DATA ASSESSMENT, CURATION, VALIDATION, SYNTHETIC DATA? 3.0 HIS Data management includes procedures on how data are captured, stored, analyzed, transmitted, and packaged for use across the data supply chain. No national document for data management procedures exists for the national HIS. 1.0 Electronic data management procedures or the HIS are clearly developed and documented in a nationally recognized document. 2.0 A roadmap is in place to migrate data collection and reporting from a paper system to an electronic system, complete with necessary data security safeguards. A documented mechanism is in place for maintaining 3.0 data quality throughout the data supply chain. National electronic data management processes are published and disseminated for the HIS. A standard operating procedure and/or data use plan is in place to facilitate data use by the country and its stakeholders. A data warehouse, integrating data from all HIS subsystems and allowing 4.0 for data triangulation and quality control, is fully functional and in use. Data access and use are constantly monitored, and data management systems are updated accordingly. Electronic data transmission is the default method to move data among information systems. Dashboards displaying information from multiple sources are available to decision 5.0 makers. APPENDICES Table continued on page 52 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE 27 DATA ETHICS The country has a recognized mechanism (e.g., committee or working group) for reviewing data ethics issues in the national HIS, and for updating 1.0 HIS policies, procedures, and laws, as needed. This mechanism reflects industry best practices. The country has no healthcare-specific data laws, regulatory frameworks, or ethics provisions to guide data ethics issues, including data security, 1.0 privacy, and confidentiality The country has drafted laws, policies, or a regulatory framework for data security and privacy that address issues related to health data. 2.0 The country has an approved health data regulatory framework. 3.0 The health data security and privacy laws have been implemented, and there are guidelines on how to operationalize the laws in the context of HIS. HIS users have been sensitized on the data security and 4.0 privacy laws. The government and HIS stakeholders consistently enforce the data security and privacy laws. The country has a recognized mechanism (e.g., a committee or working group) in place for reviewing data ethics issues within the national HIS, 5.0 and for updating policies, procedures, and laws, as needed. WORKFORCE 2.0 28 TRAINING OF DIGITAL HEALTH WORKFORCE Global Digital 52 In general, is training in digital health / health informatics / health information systems / biomedical informatics degree programs (in either public or 2.0 Health Index private institutions) producing trained digital health workers? There is no training available for digital health workforce available in the country. 1.0 Digital health workforce needs assessed, gaps identified and training options under development. 2.0 Professional training is available, but graduates are not yet deployed. 3.0 Trained digital health professionals available and deployed, but essential personnel gaps remain. 4.0 Enough trained digital health professionals available to support national digital health needs. 5.0 29 TRAINING OF DIGITAL HEALTH WORKFORCE Global Digital Specifically, is training in health and/or biomedical informatics (in either public or private institutions) producing trained informaticists or health 2.0 Health Index information systems specialists? There is no training available in informatics or health information systems available in the country. 1.0 Health informatics workforce needs assessed, gaps identified and training options under development. 2.0 Table continued on page 53 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE TRAINING OF DIGITAL HEALTH WORKFORCE (continued) Professional training in health informatics is available, but graduates are not yet deployed. 3.0 Trained informatics professionals available and deployed, but essential personnel gaps remain. 4.0 Enough trained health informatics professionals available to support national health information system needs. 5.0 STANDARDS AND INTEROPERABILITY 1.5 30 NATIONAL DIGITAL HEALTH ARCHITECTURE AND/OR HEALTH INFORMATION EXCHANGE Global Digital 2 Is there a national digital health (eHealth) architectural framework and/or health information exchange (HIE) established? Health Index There is no national digital health (eHealth) architectural framework and/or health information exchange (HIE) established. 1 A national digital health architecture and/or health information exchange (HIE) has been proposed, but not approved including semantic, syntactic, 2 and organizational layers. The national digital health architecture and/or health information exchange (HIE) is operable and provides core functions, such as authentication, 3 translation, storage and warehousing function, guide to what data is available and how to access it, and data interpretation. The government leads, manages, and enforces implementation of the national digital health architecture and/or the health information exchange 4 (HIE), which are fully implemented following industry standards. 53 The national digital health architecture and/or health information exchange (HIE) provides core data exchange functions and is periodically reviewed and updated to meet the needs of the changing digital health architecture. There is continuous learning, innovation, and quality control. 5 Data is actively used for national health strategic planning and budgeting. 31 HEALTH INFORMATION STANDARDS Global Digital 1 Are there digital health / health information standards for data exchange, transmission, messaging, security, privacy, and hardware? Health Index There are no digital health / health information standards for data exchange, transmission, messaging, security, privacy, and hardware. 1 There are some digital health / health information standards for data exchange, transmission, messaging, security, privacy, and hardware that 2 have been adopted and/or are used. Digital health / health information standards for data exchange, transmission, messaging, security, privacy, and hardware have been published 3 and disseminated in the country under the government’s leadership. Table continued on page 54 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE HEALTH INFORMATION STANDARDS (continued) Digital health / health information industry-based technical standards for data exchange, transmission, messaging, security, privacy, and hardware are in use in most applications and systems to ensure the availability of high-quality data. Conformance testing is routinely carried out to certify 4.0 implementers. Data standards are routinely updated, and data is actively used for monitoring and evaluating the health system and for national health strategic 5.0 planning and budgeting. INFRASTRUCTURE 1.6 32 PLANNING AND SUPPORT FOR ONGOING DIGITAL HEALTH INFRASTRUCTURE MAINTENANCE Global Digital Is there an articulated plan for supporting digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, devices, 1.0 Health Index etc.) provision and maintenance? There is no articulated plan for supporting digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, 1.0 devices, etc.) provision and maintenance. A plan for supporting digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, devices, etc.) provision and 2.0 maintenance has been developed, but not implemented. A plan for supporting digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, devices, etc.) provision and 54 maintenance has been implemented partially, but not consistently with estimated 0-25% of necessary digital health infrastructure needed in public 3.0 healthcare service sector available and in use. A plan for supporting digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, devices, etc.) provision and maintenance has been implemented partially and consistently with estimated 25-50% of necessary digital health infrastructure needed in public 4.0 healthcare service sector available and in use. Digital health infrastructure (including equipment- computers/ tablets/ phones, supplies, software, devices, etc.) is available, in use, and regularly 5.0 maintained and upgraded in >75% of public healthcare service sector. 33 DO YOU HAVE HEALTH INFORMATION SYSTEMS MONITORING AND EVALUATION IN PLAN? 1.0 HIS No tracking, or ad hoc tracking, is done of HIS interoperability activities related to plans, resources, and budgets for the national HIS. 1.0 The methods and tools to report on HIS interoperability implementation are defined and documented. 2.0 Implementation of HIS interoperability activities is regularly monitored and reviewed. Regular reports on HIS interoperability performance are 3.0 generated and disseminated to stakeholders Table continued on page 55 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE DO YOU HAVE HEALTH INFORMATION SYSTEMS MONITORING AND EVALUATION IN PLAN? (continued) Mechanisms to track and measure performance of HIS interoperability are government-approved and government-led. 4.0 The regular monitoring of HIS interoperability influences decisions about leadership, governance, resources, and technology. 5.0 34 ARE THERE PLANS RELATED WITH BUSINESS CONTINUITY IF A DISRUPTIVE INCIDENT HAPPENS? 1.0 HIS There is no government-approved business continuity plan (BCP) in place for the national or subnational levels of the HIS. 1.0 The HIS has developed a BCP that outlines the processes needed to ensure continuity of critical business processes. 2.0 The BCP implementation has been audited. Audit results show that at least 50% of the BCP has 3.0 been implemented. Audit results show that at least 75% of the BCP has been implemented. 4.0 Audit results show that all or most of the BCP has been implemented. 5.0 University of Chicago 35 HOW ACCESSIBLE IS THE DATA THAT'S REQUIRED? 1.0 (Adapted) Only accessible within the application where it is collected 1.0 55 Can be accessible outside the application but proprietary format, requiring specialized analysis software 2.0 All machine readable in standard open format (CSV, JSON, XML, database) 4.0 All machine readable in standard open format and available through an API 5.0 36 HOW IS THE DATA STORED? 5.0 University of Chicago Paper 1.0 PDFs or Images 2.0 Text Files 4.0 Databases 5.0 37 HOW INTEGRATED ARE THE DIFFERENT DATA SOURCES? 1.0 University of Chicago Data sits in the source systems 1.0 Data is exported occasionally and integrated in ad hoc manner 2.0 Table continued on page 56 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE HOW INTEGRATED ARE THE DIFFERENT DATA SOURCES? (continued) Central data warehouse - real-time aggregation and linking (Automatic) 4.0 External data also integrated 5.0 38 HOW MUCH HISTORY IS STORED AND HOW ARE UPDATES HANDLED? 2.0 University of Chicago No History Kept - old data is deleted 1.0 Historical data is stored but updates overwrite existing data 2.0 Historical data is stored, and new data gets appended with timestamp, preserving old values 4.0 All history is kept, and new data schema gets mapped to old schema so older data can be used 5.0 39 HOW MUCH IS DATA FRAGMENTED IN SILOS? 2.0 World Bank All healthcare information is fragmented in different silos, and it is not interoperable 1.0 Some healthcare information is still fragmented and not interoperable, some databases are interoperable 2.0 Few healthcare information is still fragmented and not interoperable, most databases are interoperable 3.0 56 All databases related to healthcare are interoperable, but are still saved in silos 4.0 There is one big database containing all the healthcare related information 5.0 40 WOULD YOU DEFINE THE CURRENT SYSTEMS IN THE COUNTRY AS "LEGACY SYSTEMS" (In computing, a legacy system is an old method, technology, computer system, or application program, "of, relating to, or being a previous or outdated computer system," yet still in use. Often 2.0 World Bank referencing a system as "legacy" means that it paved the way for the standards that would follow it. Wikipedia) All systems are defined as Legacy and are currently outdated 1.0 75% of systems are defined as Legacy 2.0 50% of systems are defined as Legacy 3.0 25% of systems are defined as Legacy 4.0 All systems have been updated. 5.0 Table continued on page 57 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE 41 INCIDENT RESPONSE: University of Oxford - 1.0 IDENTIFICATION OF INCIDENTS Cyber Maturity Model No catalogue of national level incidents exists or is in development. 1.0 Certain cybersecurity incidents have been categorized and recorded as national-level threats. 2.0 A central registry of national-level cybersecurity incidents is operational. 3.0 Regular, systematic updates to the national-level incident registry are made. Resources are allocated for analyzing incidents in order to prioritize 4.0 which incidents are most urgent. Focus on incident identification and analysis is adapted in response to environmental changes. 5.0 42 INCIDENT RESPONSE: University of Oxford - 1.0 MODE OF OPERATION Cyber Maturity Model Key incident response processes (detection, resolution, prevention, etc.) and (digital) tools to support them have not been well defined or 1.0 documented. There is limited or no sufficient training or understanding of the key concepts of cybersecurity incident response. Key incident response processes have been identified, but not officially documented or operationalized. Members of CSIRTs receive training in an 2.0. ad-hoc manner. Incident response is reactive and ad-hoc. 57 Key incident response processes and tools are defined, documented and functional. Members of CSIRTs receive training regularly to understand 3.0 key concepts of cybersecurity incident response. National-level incident response is limited in scope and still reactive. Incident response teams have established a training policy for their members; members are being trained in specialized subjects and accredited by internationally recognized bodies on a regular basis. Team members can carry out a sophisticated incident analysis investigation quickly and 4.0 efficiently. Key processes (detection, resolution, prevention, etc.) are being monitored and reviewed in regular basis and tested with different case scenarios. Forensics services are offered. National incident response teams coordinate with international counterparts. The results of testing key processes through case scenarios are being analyzed and are incorporated into the updating of processes. The benefits of training and accreditation are being evaluated and inform the future training planning. Tools for early detection, identification, prevention, 5.0 response and mitigation of zero-day vulnerabilities are embedded in incident response organization(s). Mechanisms for regional cooperation in incident response have been established. Table continued on page 58 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE 43 CRITICAL INFRASTRUCTURE PROTECTION: University of Oxford - 1.0 RISK MANAGEMENT AND RESPONSE Cyber Maturity Model Risk management skills and understanding may be incorporated into business practices, but cybersecurity, if recognized, is subsumed into IT and data protection risk and is not recognized as a priority. Response planning and threat awareness may have been broadly discussed, but no formal 1.0 plan exists. Physical and virtual access control is implemented. CI has basic capacity to detect, identify, respond to and recover from cyber threats, but such capabilities are uncoordinated and vary in quality. Protection of CI assets includes basic level cybersecurity awareness and data security policies, 2.0 but no protection processes have been agreed. Best practices in security measures, guidelines, and standards for CI cybersecurity have been established and adopted. Cybersecurity risk management processes have been established, supported by adequate technical security solutions, communication links, and harm mitigation 3.0 measures. CI risk management procedures are used to create a national response plan including the participation of all vital entities. Cybersecurity is firmly embedded into general risk management practice. Assessment of the breadth and severity of harm incurred by CI assets is regularly conducted and response planning is tailored to that assessment to ensure business continuity. Resources are allocated in proportion to 4.0 the assessed impact of an incident to ensure rapid and effective incident response. Insider threat detection is accounted for. Audit practices to assess network and system dependencies and vulnerabilities (e.g., unmitigated dependencies) are implemented on a regular basis and inform continuous reassessment of CI risk portfolio, technologies, policies, and processes. The impact of cybersecurity risk on the 58 5.0 business operations of CI, including direct and opportunity costs, impact on revenue, and hindrance to innovation, are understood and incorporated into future planning and executive decision making. SERVICES AND APPLICATIONS 3.2 44 DIGITAL IDENTITY MANAGEMENT OF INDIVIDUALS FOR HEALTH: Global Digital Health ARE SECURE REGISTRIES OR A MASTER PATIENT INDEX OF UNIQUELY IDENTIFIABLE INDIVIDUALS AVAILABLE, ACCESSIBLE AND 2.0 Index CURRENT FOR USE FOR HEALTH-RELATED PURPOSES? No secure registry or master patient index exists. 1.0 A secure registry exists, but is incomplete / partially available, used, and irregularly maintained. 2.0 A secure registry exists, is available and in active use and includes <25% of the relevant population. 3.0 A secure registry exists, is available and in active use and includes 25‒50% of the relevant population. 4.0 A secure registry exists, is available and in active use and includes >75% of the relevant population. The data is available, used, and curated. 5.0 Table continued on page 59 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE 45 DIGITAL IDENTITY MANAGEMENT OF INDIVIDUALS FOR HEALTH: Global Digital SPECIFICALLY, IS THERE A SECURE MASTER PATIENT INDEX of uniquely identifiable individuals available, accessible, and current that is used 2.0 Health Index for health-related purposes? No secure master patient index exists. 1.0 A master patient index exists, but is incomplete / partially available, used, and irregularly maintained. 2.0 A master patient index exists, is available and in active use and includes <25% of the relevant population. 3.0 A master patient index exists, is available and in active use and includes 25‒50% of the relevant population. 4.0 A master patient index exists, is available and in active use and includes >75% of the relevant population. The data is available, used, and 5.0 curated. 46 DIGITAL IDENTITY MANAGEMENT OF INDIVIDUALS FOR HEALTH: Global Digital SPECIFICALLY, IS THERE A SECURE BIRTH REGISTRY of uniquely identifiable individuals available, accessible, and current for use for health- 5.0 Health Index related purposes? No secure birth registry exists. 1.0 A secure birth registry exists, but is incomplete / partially available, used, and irregularly maintained. 2.0 59 A secure birth registry exists, is available and in active use and includes <25% of the relevant population. 3.0 A secure birth registry exists, is available and in active use and includes 25‒50% of the relevant population. 4.0 A secure birth registry exists, is available and in active use and includes >75% of the relevant population. The data is available, used, and curated. 5.0 47 DIGITAL IDENTITY MANAGEMENT OF INDIVIDUALS FOR HEALTH: Global Digital SPECIFICALLY, IS THERE A SECURE DEATH REGISTRY of uniquely identifiable individuals available, accessible, and current for use for health- 5.0 Health Index related purposes? No secure death registry exists. 1.0 A secure death registry exists, but is incomplete / partially available, used, and irregularly maintained. 2.0 A secure death registry exists, is available and in active use and includes <25% of the relevant population. 3.0 A secure death registry exists, is available and in active use and includes 25‒50% of the relevant population. 4.0 A secure death registry exists, is available and in active use and includes >75% of the relevant population. The data is available, used, and 5.0 curated. Table continued on page 60 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ARCHITECTURE AND DATA INDICATORS SCORE SOURCE 48 DIGITAL IDENTITY MANAGEMENT OF INDIVIDUALS FOR HEALTH: Global Digital SPECIFICALLY, IS THERE A SECURE IMMUNIZATION REGISTRY of uniquely identifiable individuals available, accessible and current for use for 2.0 Health Index health-related purposes? No secure immunization registry exists. 1.0 A secure immunization registry exists, but is incomplete / partially available, used, and irregularly maintained. 2.0 A secure immunization registry exists, is available and in active use and includes <25% of the relevant population. 3.0 A secure immunization registry exists, is available and in active use and includes 25‒50% of the relevant population. 4.0 A secure immunization registry exists, is available and in active use and includes >75% of the relevant population. The data is available, used, and 5.0 curated. 49 ARE THERE ANY HEALTHCARE SERVICES USING CLOUD COMPUTING? 3.0 World Bank No cloud services are used 1.0 There are discussions to transfer services to cloud services 2.0 Some services are cloud-based 3.0 60 Most services are cloud-based 4.0 All online services used cloud servers 5.0 Table continued on page 61 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) C. APPLICATIONS INDICATORS SCORE SOURCE APPLICATIONS (TOTAL SCORE) 1.09 The following indicators refer to topics related with digital health applications to deliver quality care to patients LEADERSHIP AND GOVERNANCE STRATEGY AND INVESTMENT 2.0 50 STRUCTURED PILOTISM TO COUNTER FRAGMENTATION: Broadband The umbrella structure for coordinated piloting is integrated into the larger ecosystem of scaled and operational AI in health solutions as well as into 2.0 Commission - AI cross-sectoral working groups. Funding opportunities can be managed through a centralized platform designed for funders and donors (Adapted) No pilots going in the country 1.0 Pilotism is supported by a broad remit of actors ranging from IOs, INGOs, and governments; however, there is little or no coordination between 2.0 disparate pilot projects The value of innovative pilotism is widely recognized by public-private actors and is brought under an organizational umbrella to maximize value 4.0 generation while minimizing duplication and a lack of coordination The umbrella structure for coordinated piloting is integrated into the larger ecosystem of scaled and operational AI in health solutions as well as 5.0 into cross-sectoral working groups. Funding opportunities can be managed through a centralized platform designed for funders and donors 61 Global Digital LEGISLATION AND POLICY 1.0 Health Index 51 PROTOCOL FOR REGULATING OR CERTIFYING DEVICES AND/OR DIGITAL HEALTH SERVICES Are there protocols, policies, frameworks or accepted processes governing the clinical and patient care use of connected medical devices and digital 1.0 health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care? There are no protocols, policies, frameworks, or accepted processes governing the clinical and patient care use of connected medical devices and 1.0 digital health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care. Protocols, policies, frameworks, or accepted processes governing the clinical and patient care use of connected medical devices and digital health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care have been proposed and are under 2.0 review. Table continued on page 62 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) APPLICATIONS INDICATORS SCORE SOURCE PROTOCOL FOR REGULATING OR CERTIFYING DEVICES AND/OR DIGITAL HEALTH SERVICES (continued) Protocols, policies, frameworks, or accepted processes governing the clinical and patient care use of connected medical devices and digital health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care have been passed, but are not fully 3.0 implemented. Protocols, policies, frameworks, or accepted processes governing the clinical and patient care use of connected medical devices and digital health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care have been implemented, but not 4.0 consistently enforced. Protocols, policies, frameworks, or accepted processes governing the clinical and patient care use of connected medical devices and digital health services (e.g., telemedicine, applications), particularly in relation to safety, data integrity and quality of care have been implemented and are 5.0 enforced consistently. 52 DOES THE GOVERNMENT HAVE A POLICY ON UTILIZATION OF SOCIAL MEDIA FOR HEALTHCARE COMMUNICATION, PREVENTION, Global Observatory 1.0 INFORMATION? of eHealth There is no utilization of social medial for healthcare purposes 10. There is a strategy to use social media 2.0 The government has an extensive use of social media to inform 3.0 62 The government has an extensive use of social media to inform, prevent, share 4.0 The government has an extensive use of social media to inform, prevent, share and also analyze social media to track and find patterns 5.0 WORKFORCE 1.0 53 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL IN-SERVICE TRAINING (AFTER DEPLOYMENT) Global Digital SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR HEALTH AND HEALTH-RELATED SUPPORT PROFESSIONALS in the 1.0 Health Index workforce in general? [Defined as community health workers, nurses, doctors, allied health, health managers/administrators, and technologists] There is no digital health curriculum as part of in-service (continuing education) training for health professionals in the workforce. 1.0 Digital health curriculum proposed and under review as part of in-service (continuing education) training for health professionals in the workforce. 2.0 Digital health curriculum is implemented as part of in-service (continuing education) training for 0‒25% health professionals in the workforce. 3.0 Digital health curriculum is implemented as part of in-service (continuing education) training for 50‒75% health professionals in the workforce. 4.0 Digital health curriculum is implemented as part of in-service (continuing education) training for >75% health professionals in the workforce. 5.0. Table continued on page 63 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) APPLICATIONS INDICATORS SCORE SOURCE 54 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL IN-SERVICE TRAINING (AFTER DEPLOYMENT) Global Digital 10 SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR DOCTORS/PHYSICIANS IN THE WORKFORCE? Health Index There is no digital health curriculum as part of in-service (continuing education) training for doctors/physicians in the workforce. 1.0. Digital health curriculum proposed and under review as part of in-service (continuing education) training for doctors/physicians in the workforce. 20. Digital health curriculum is implemented as part of in-service (continuing education) training for 0‒25% of doctors/physicians in the workforce. 3.0 Digital health curriculum is implemented as part of in-service (continuing education) training for 50‒75% of doctors/physicians in the workforce. 4.0 Digital health curriculum is implemented as part of in-service (continuing education) training for >75% of doctors/physicians in the workforce. 5.0. 55 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL IN-SERVICE TRAINING (AFTER DEPLOYMENT) Global Digital 1.0 SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR NURSES IN THE WORKFORCE? Health Index There is no digital health curriculum as part of in-service (continuing education) training for nurses in the workforce. 1.0 Digital health curriculum proposed and under review as part of in-service (continuing education) training for nurses in the workforce. 2.0 Digital health curriculum is implemented as part of in-service (continuing education) training for 0‒25% of nurses in the workforce. 3.0. Digital health curriculum is implemented as part of in-service (continuing education) training for 50‒75% of nurses in the workforce. 4.0 63 Digital health curriculum is implemented as part of in-service (continuing education) training for >75% of nurses in the workforce. 5.0 56 DIGITAL HEALTH INTEGRATED IN HEALTH AND RELATED PROFESSIONAL IN-SERVICE TRAINING (AFTER DEPLOYMENT) Global Digital 1.0 SPECIFICALLY, IS DIGITAL HEALTH PART OF CURRICULUM FOR COMMUNITY HEALTH WORKERS IN THE WORKFORCE? Health Index There is no digital health curriculum as part of in-service (continuing education) training for community health workers in the workforce. 1.0. Digital health curriculum proposed and under review as part of in-service (continuing education) training for community health workers in the 2.0 workforce. Digital health curriculum is implemented as part of in-service (continuing education) training for 0‒25% of community health workers in the 3.0 workforce. Digital health curriculum is implemented as part of in-service (continuing education) training for 50‒75% of community health workers in the 4.0 workforce. Digital health curriculum is implemented as part of in-service (continuing education) training for >75% of community health workers in the 5.0 workforce. Table continued on page 64 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) APPLICATIONS INDICATORS SCORE SOURCE STANDARDS AND Global Digital 1.0 INTEROPERABILITY Health Index 57 HEALTH SYSTEM AND WORKFLOW INTEGRATION AI solutions are an essential and integrated component of the health system, with outcome reviews built into regular cost-benefit analyses. Integration Broadband 1.0 into the health system is streamlined and follows clearly outlined processes, and can be completed with relative ease thanks to robust guidelines, Commission - AI agile health organizations, and predefined workflows Valuable AI technologies are not systematically integrated into the existing health system, but require individual adoption processes and protocols 1.0. for the government/Ministry of Health/health organization implementing them Government agencies and health system managers start to work together to give guidance on AI health system integration 2.0 National guidelines on integrating AI-driven health solutions have been co-created by relevant government agencies and health players 3.0 The integration of AI solutions into clinical workflows is enabled through stepwise protocols and targeted guidelines and rules on clinical processes, equipment requirements, and information generation/consumption. Clinical workflows have been updated or are easily updatable due 4.0 to the advances of digital and AI technologies AI solutions are an essential and integrated component of the health system, with outcome reviews built into regular cost-benefit analyses. Integration into the health system is streamlined and follows clearly outlined processes and can be completed with relative ease thanks to robust 64 guidelines, agile health organizations, and predefined workflows. In addition to robust guidelines, a working group for the continuous improvement of AI health system integration has been set up and provides frequent updated guidance. Clinical workflows and AI solutions are fully integrated 5.0 processes and an important dimension of the health system ecosystem. All relevant medical equipment is a connected device. Guidelines are regularly updated and adapted to new technological specifications. The benefits and health outcomes of AI solutions are continuously measured and directly influence decision-making processes and BI INFRASTRUCTURE SERVICES AND APPLICATIONS 58 ARE THERE ANY DECISION SUPPORT SYSTEMS IMPLEMENTED IN ANY HEALTHCARE WORKFLOW? 1.0 World Bank No 1.0 Yes 5.0 59 NUMBER OF SERVICES THAT CAN BE PROVIDED DIGITALLY 1.0 World Bank 0‒20% 1.0 20‒40% 2.0 Table continued on page 65 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) APPLICATIONS INDICATORS SCORE SOURCE NUMBER OF SERVICES THAT CAN BE PROVIDED DIGITALLY (continued) 40‒60% 3.0 60‒80% 4.0 80‒100% 5.0 60 DIGITAL IDENTITY MANAGEMENT OF SERVICE PROVIDERS, ADMINISTRATORS, AND FACILITIES FOR DIGITAL HEALTH, INCLUDING LOCATION DATA FOR GIS MAPPING Global Digital 1.0 Are health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) available, accessible, and Health Index current? Is the data geotagged to enable GIS mapping? Health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) are not available, 1.0 accessible, and current. Health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) are being developed but 2.0 are not available for use. Health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) are available for use, but 3.0 incomplete, partially available, used sporadically, and irregularly maintained. 65 Health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) are available, used, and 4.0 regularly updated and maintained. The data is geo-tagged to enable GIS mapping. Health system registries of uniquely identifiable providers, administrators, and public facilities (and private if applicable) are available, up to date 5.0 with geo-tagged data and used for health system and service strategic planning and budgeting. Table continued on page 66 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) D. ANALYTICS INDICATORS SCORE SOURCE ANALYTICS (TOTAL SCORE) 1.6 The following indicators refer to the maturity of AI, the utilization of data, the knowledge in data science among healthcare workers, AI strategy LEADERSHIP AND GOVERNANCE 1.4 61 LEADERSHIP Broadband Creating an integrated AI for health ecosystem across the full application spectrum is a top priority at the highest levels of government and for 1.0 Commission industry leaders The government supports the implementation of AI for health on an ad hoc basis, and top-level support is often missing 1.0 The government systematically supports the incorporation of AI into healthcare at a leadership level 2.0 National agencies for key governance and regulatory AI dimensions are established and supported by political leadership 3.0 Creating an integrated AI for health ecosystem across the full application spectrum is a top priority at the highest levels of government and for 4.0 industry leaders A digital/AI unit is formally established within the Ministry of Health/ICT. Support stretches across key ministries 5.0 and executive offices 62 AI GOVERNANCE AND STEWARDSHIP Broadband 66 Data, algorithm, model, digital technology, ethical and workforce policies, are sufficiently robust to achieve the strategic national transformation for a 1.0 Commission data-driven health future. Health data management accountability is formalized but not centralized. Rules, standards, and guidelines are not defined nationally 1.0 Data, algorithm, model, digital technology, ethical, and workforce policies inform the governance, acquisition, ingestion, transformation, and use 2.0 of data in health, according to public health priorities National data stewardship efforts create a public sector platform for creating and managing health data, documenting relevant rules and 3.0 standards, and managing data quality National data stewardship efforts define guidelines for data controls, rules and uses that are underpinned by policy and champion all data as an 4.0 asset for public health. There are concerted national efforts to comply with and co-shape international standards and policy frameworks Data stewardship is formalized and ensures that data policies and standards are turned into practice, including regular audits 5.0 Table continued on page 67 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ANALYTICS INDICATORS SCORE SOURCE 63 HOW DOES LEADERSHIP VALUE DATA? University of 2.0. Do they require data to be presented to make decisions? Chicago Leaders at this level fundamentally don't know how data can help advance the organization's mission. 1.0 Leadership wants to use data but don't have a clear path forward to use data 2.0 Leadership has a clear idea of how data can be used to drive business decisions beyond justification of funding 4.0 Leadership builds a culture of data within the organization and demands data to justify all programmatic decisions 5.0 STRATEGY AND INVESTMENT 1.0 64 STRATEGY & BUDGET: Broadband 1.0 AI STRATEGY FULLY BUDGETED Commission Budgets have not been granted or earmarked for digital health, although individual AI in health solutions may be supported opportunistically 1.0 National public health priorities and the role of AI are described in an official document 2.0 The government has published and is operationalizing its AI strategy or a digital health strategy with specific articles on AI, and has allocated 3.0 dedicated funding (e.g., a percentage of the overall health budget) for AI pathways that support national health priorities 67 There is a dedicated national AI in health strategy that directly links national AI strategies from different sectors with the aim of cross-sectoral 4.0 support and a learning ecosystem. The strategy is fully budgeted and integrated into the overall health roadmap for multiple years Dedicated agencies and good governance stewards oversee implementation, outcome measurement, and continuous support. Open innovation 5.0 is systematically integrated into national strategies and an essential part of the larger innovation ecosystem that is creating new value chains 65 BUSINESS MODELS Broadband 1.0 Health system players are scaling product and business models to target large NGO, commercial, or government adoption of AI solutions Commission Sustainable business models have been introduced with limited scope and no national guidance exists 1.0 National funding for AI in health is not led by dedicated budgets but builds on existing budgets 2.0 Health system players are testing and piloting sustainable business models, while still largely relying on external funding 3.0 AI in health has a nationally dedicated budget and forecasts for long-term sustainability 4.0 Health system players are scaling product and business models to target large NGO, commercial, or government adoption of AI solutions 5.0 Table continued on page 68 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ANALYTICS INDICATORS SCORE SOURCE LEGISLATION AND POLICY 1.5 66 ARE THERE POLICIES IN PLACE AROUND THE NEED FOR Broadband 1.0 EXPLAINABILITY/FAIRNESS/TRANSPARENCY IN AI MODELS? Commission AI explainability requirements have not been established, but national efforts exist to provide technical explainability guidelines (e.g., guidance on making AI systems understandable and traceable to humans). While there is no consensus around algorithm and model transparency and bias, 1.0 the government is establishing a working group to propose recommendations AI explainability requirements have not been established 2.0 AI explainability requirements are formalized for applications requiring regulatory approvals and strong guidelines are in place for others 3.0 Beyond technical explainability, this includes interpretability requirements enabling physicians to transparently explain to patients proposed 4.0 decisions for informed patient consent AI explainability is closely regulated and government support extends beyond explainability and interpretability to foster transparent, re-enactive, 5.0 comprehensible, retraceable, and reproducible models or self-explaining agents 67 THERE IS A WRITTEN SET OF PROCEDURES IS4H Maturity 2.0 FOR DATA ANALYSIS? Assessment tool 68 No procedures 1.0 Some procedures 2.0 Procedures and policies documented but not fully implemented 3.0 Procedures and policies documented and implemented at the region and national levels 4.0 Procedures and policies documented and implemented at the facility, region and national levels 5.0 WORKFORCE 1.3 68 HOW BOUGHT IN ARE STAFF THROUGHOUT THE GOVERNMENT/MINISTRY OF HEALTH/HEALTH ORGANIZATION? WHAT University of 2.0 PERCENTAGE OF THE STAFF ARE INVOLVED IN DATA COLLECTION? DATA ANALYSIS? Chicago Staff at the government/Ministry of Health/health organization have some idea that data exists but doesn't understand it is important 1.0. There are a few individuals who deeply understand the data available and what can be done with it 2.0 Table continued on page 69 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ANALYTICS INDICATORS SCORE SOURCE HOW BOUGHT IN ARE STAFF THROUGHOUT THE GOVERNMENT/MINISTRY OF HEALTH/HEALTH ORGANIZATION? WHAT PERCENTAGE OF THE STAFF ARE INVOLVED IN DATA COLLECTION? DATA ANALYSIS? (continued) The government/Ministry of Health/health organization has a clear idea of how data can be used to drive business decisions beyond justification 4.0 of funding The government/Ministry of Health/health organization has a culture of data within the organization and demands data to justify all programmatic 5.0 decisions 69 NATIONAL CURRICULA AND EDUCATION INSTITUTIONS Broadband 1.0 (DATA SCIENCE AND AI) Commission National curricula for health in tertiary education do not include Data Sciences and AI (DSAI) 1.0 Government actions are focused on drafting policies for DSAI to become part of formal health education 2.0. Selected health driven DSAI courses are compulsory for higher education programs in health 3.0 Public health priorities and the role of DSAI are taught at the basic level in secondary education. Government is prioritizing university research on 4.0 DSAI in health through funding and incentives (tax benefits, Centers of Excellence, etc.) Secondary school curricula introduce basic DSAI concepts. DSAI skills are mandatory for medical and health-related degrees. Higher education 5.0 69 institutions not only prioritize teaching and research in DSAI for health, but they also incubate national cross-sectoral collaborations 70 PROFESSIONAL AND ON-THE-JOB TRAINING Broadband 1.0. (DATA SCIENCE & AI) Commission Professional DSAI trainings in health are not compulsory for specialized health workers and course offerings are restricted to basic courses. Development of technology skills is rarely part of continuous learning opportunities for health staff. No continuous education curricula for in- 1.0 service training of health staff have been drafted Social learning is supported by key actors but lacks systematic support 2.0 Training programs on DSAI in health are closely aligned with public health priorities. Health systems are actively prioritizing the extension of 3.0 trainings from specialized medical workers to general health workers. Continuous and social learning on AI in health is an integrated part of on-the-job training goals 4.0 Certified trainings in DSAI in health are mandatory on a national level for all relevant health professionals and are fully aligned with public health priorities. National actors work towards international recognition of training certifications and public-private sector trainings are initiated for 5.0 upskilling and knowledge exchange. Continuous learning on AI in health is compulsory for most medical and health workers Table continued on page 70 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ANALYTICS INDICATORS SCORE SOURCE 71 TALENT ACQUISITION Broadband 1.0 (DATA SCIENCE & AI) Commission There is no national strategy to attract and retain DSAI talents, yet the government is defining its first strategies to attract talent, e.g., through 1.0 innovation parks, research hubs, strong workers’ rights and benefits, and streamlined processes for integrating innovation into public sectors Attracting and retaining AI and talent with both expertise in health and DSAI is anchored in policy initiatives and supported through financial or tax 4.0 incentives Existing efforts to retain key talent are supplemented by the establishment of prestigious grants, grand challenges, and adjunct research positions 5.0 for thought-leaders from both private and public sectors STANDARDS AND INTEROPERABILITY INFRASTRUCTURE 3.0 72 ONLINE TOOLS AND PLATFORMS FOR DATA DISSEMINATION IS4H Maturity 3.0 AND ANALYSIS ARE AVAILABLE Assessment tool Not available 1.0. For private use of technical team 2.0 70 For decisions makers 3.0 For stakeholders 4.0 For public 5.0 SERVICES AND APPLICATIONS 2.4 73 DOES THE HEALTHCARE SECTOR USE DATA CONSUMPTION Broadband 2.0 AND BUSINESS INTELLIGENCE SERVICES? Commission No business intelligence is integrated 1.0 Basic data consumption and business intelligence metrics are integrated into essential operating processes, e.g., dashboards and interfaces to steer decision-making on how the government/Ministry of Health/health organization is deriving value from data, what data is used, how it is 3.0 accessed, which decisions are data-driven, etc. Advanced data consumption and business intelligence metrics, including advanced real-time analytics on outcomes and value generation as well as live feeds on workflow integration, create an ecosystem of data-driven decision making across the health system and the government/Ministry 5.0 of Health/health organization’s business processes Table continued on page 71 Appendix table C.1 Indicators of Digital Maturity in Lesotho (continued) ANALYTICS INDICATORS SCORE SOURCE 74 ADVANCED ANALYTICAL TECHNIQUES (E.G., AI, PREDICTIVE ANALYSIS, NATURAL LANGUAGE PROCESSING, ETC.) ARE IS4H Maturity 1.0 APPLIED TO SUPPORT REAL-TIME AND ROUTINE CLINICAL, MANAGEMENT AND POLICY DECISION-MAKING. Assessment tool No 1.0 Not on a regular basis 2.0 Ad hoc 3.0 On demand 4.0 Routinely 5.0 75 TOOLS USED TO SUPPORT IS4H Maturity 4.0 HEALTH ANALYSIS Assessment tool No tools 1.0 Spreadsheets (Excel) 2.0 Graphing tools and statistical packages (R, SPSS, SAS). 3.0 Business intelligence tools and dashboards. 4.0 71 GPS data sets, data warehouses, visualization tools and analytical presentation tools available through websites 5.0 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES APPENDIX D PROFILE OF DIGITAL HEALTH LANDSCAPE Appendix table D.1 Socio-demographics and healthcare system basic information LESOTHO BOTSWANA ESWATINI NAMIBIA SOUTH AFRICA YEAR SOURCE Population, total (millions) 2.14 2.35 1.16 2.54 59.31 2020 World Bank Population growth (annual %) 0.8% 2.1% 1.0% 1.8% 1.3% 2020 World Bank Population density (people per sq. km of land area) 69 4 66 3 48 2020 World Bank Rural population (% of total) 71% 29% 76% 48% 33% 2020 World Bank Life expectancy at birth, total (years) 54 70 60 64 64 2019 World Bank GDP per capita, PPP (constant 2017 international $) 2,280 16,040 8,393 8,894 11,466 2019 World Bank GDP per capita growth (annual %) -11.8% -9.8% -2.7% -9.7% -8.1% 2020 World Bank Income level LMI UMI LMI UMI UMI ‒ World Bank Hospital beds (per 1,000 people) 1.3 1.8 2.1 2.7 2.3 Various World Bank Physicians (per 1,000 people) 0.1 0.5 0.3 0.4 0.9 Various World Bank 72 Nurses and midwives (per 1,000 people) 3.3 5.4 4.1 2.0 1.3 Various World Bank Health expenditure as % of GDP 9.28% 5.85% 6.54% 7.95% 8.25% 2018 World Bank Out-of-pocket expenditure (% of current health expenditure) 16.04% 3.32% 11.26% 8.43% 7.72% 2018 World Bank Appendix table D.2 Digital Environment and Infrastructure LESOTHO BOTSWANA ESWATINI NAMIBIA SOUTH AFRICA YEAR SOURCE E-Government development index (out of 193) 135 115 128 104 78 2020 UN ICT development index (out of 176) 133 105 ‒ 118 92 2017 ITU Access to electricity (% of population) 47 70 77 55 85 2019 World Bank Mobile-cellular subscriptions (per 100 inhabitants) 74 163 94 113 166 2019 World Bank Fixed-telephone subscriptions (per 100 inhabitants) 1 6 4 6 3 2019 World Bank Table continued on page 73 Appendix table D.2 Digital Environment and Infrastructure (continued) LESOTHO BOTSWANA ESWATINI NAMIBIA SOUTH AFRICA YEAR SOURCE Mobile-cellular basket low usage 6.85 1.05 1.62 1.95 1.55 2019 ITU (70 min + 20 SMS) (%GNI pc) Individuals using internet (% of population) 29 47 47 51 56 2019 ITU Percentage of households with computers 8.86 27.80 21.40 21.19 21.85 2019 ITU Percentage of households with internet access 30.42 63.45 27.00 34.57 61.83 2019 ITU TYPE OF COVERAGE AND % OF POPULATION 2G 90% ‒ ‒ ‒ ‒ ‒ GSMA 3G 90% ‒ ‒ ‒ ‒ ‒ GSMA 4G 45% ‒ ‒ ‒ ‒ ‒ GSMA Mobile coverage gap 15% ‒ ‒ ‒ ‒ ‒ GSMA Mobile utilization gap 55% ‒ ‒ ‒ ‒ ‒ GSMA 73 Appendix table D.3 Digital Health Applications and Interventions INDICATOR YEAR SOURCE No. or percentage of population registered in the national EMR Only HIV/TB patients No. of health facilities using EHR 182 2021 No. of health facilities using national EMR 182 2021 Percentage of health facilities connected to the internet at least 182 2021 IS THE NATIONAL EMR INTEGRATED WITH: Laboratory info No 2020 Radiology/PACS No 2020 Pharmacy info Work in progress 2021 Table continued on page 74 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table D.3 Digital Health Applications and Interventions (continued) INDICATOR YEAR SOURCE IS THE NATIONAL EMR INTEGRATED WITH (continued): Drug procurement No 2020 Electronomical medical billing No 2020 HR No 2020 WHAT KIND OF DIGITAL HEALTH INTERVENTIONS EXISTS IN THE COUNTRY? Appointment reminders No 2020 ICAP Mobile telehealth No 2020 Management of disasters and emergencies No 2020 Treatment adherence Yes (only HIV/TB) 2020 Community mobilization No 2020 Access to information, databases, and tools No 2020 Patient records Yes (only HIV/TB) 2020 74 eLearning No 2020 Decision support systems No 2020 Patient monitoring No 2020 Disease surveillance Yes 2020 Other (name) Reporting 2020 APPENDICES APPENDIX E KEY ACHIEVEMENTS OF THE EHEALTH STRATEGY (2019‒2023) BY STRATEGIC AREA Focus Area - ICT Services and Applications:  Identified the HIE platform  Selected the HIE architecture  Acquired the hardware  Configured and tested the software  Assessed all facilities with or without VoIP  Procured VoIP infrastructure  Installed and configured VoIP infrastructure  Trained personnel/users on use of VoIP  Provided support and maintenance  Identified plausible systems supporting voice and video  Identified hardware supporting systems  Acquired software compatible with the hardware chosen  Installed, configured, and tested the solution  Assessed OpenLMIS  Identified modules to be customized  Customized (prototyping) the modules according to specifications  Trained users and piloted the system  Rolled out the system to all facilities  Assessed the IHRIS  Identified modules to be customized  Conducted a readiness assessment of all health centers beyond the current 45 e-Register implementing sites  Procured infrastructure for sites without e-Register  Installed and configured infrastructure  Added modules to the e-Register to accommodate all programs  Assessed available Open-Source Shared Health Record Applications 75 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Focus Area - Leadership and Governance: Minimal Focus Area - Strategy and Investment:  Finalized the development of the National eHealth Strategy 2019–2023  Incorporated comments from the validation workshop and finalized the eHealth strategy  Submitted the final version of the eHealth Strategy for political endorsement  Promoted the eHealth strategy for buy-in across all MoH departments and GoL sectors and stakeholders  Identified key departments and stakeholders to promote eHealth  Sourced funding from stakeholders and development partners  Identified potential sources of funding Focus Area - Infrastructure  Upgraded the government network  Assessed and identified the end-of-life devices to be upgraded  Improved cybersecurity for the MoH  Acquire SSL certificates  Expanded the network to all health facilities  Assessed status of network coverage at health facilities  Upgraded MoH server capacity to boost the speed of the eHealth system  Procured adequate equipment  Installed equipment  Improved security of the data center server  Secured the data center premises Focus Area - Standards and Interoperability: Minimal Focus Area - Workforce:  Mobilized institutions of higher learning to provide eHealth training programs  Established partnerships with local Institutions of higher learning 76 APPENDICES APPENDIX F PRINCIPLES OF PARTICIPATORY DESIGN Participatory design and implementation of digital health care and health care digitization refer to the adoption, integration, and sustainability of new systems. It is a collaborative method that requires creative partnerships between developers and end-users, specifically in the context of technology, to enable users to design their experiences with modern technology in a formative design stage, to collectively propose solutions to improve use in practice. Failure to incorporate participatory design and implementation may lead to wasted resources and create new challenges on the ground and to end-users. Participatory design requires repeated engagement with all stakeholders and their perspectives as well as use of digital technology, integration with existing information systems, and standardized delivery at scale. Co-design with all intended users is necessary, including consideration of patients' experiences to note differences in how users view digital interventions compared to health care workers and providers, which can impact engagement throughout the health system. It is recommended that the principles of participatory design and implementation guide the development of every component of strategies and actions to support the uptake and integration of digital health and health digitalization. Participatory design and implementation processes typically involve using visual or narrative methods understand better the needs and circumstances of end-users, as well as rapid prototyping to critique assumptions and proposed solutions to complex health care problems. Key actionable means to be considered in participatory design and implementation include the following:  Empathy mapping during data collection to gain insight and determine end-users’ pain points and challenges  Conceptual design and data analyses using the living lab approach, following a predetermined set of end-users of different perspectives and profiles in real-world environments  Focus group prototyping with end-users to predict reactions prior to completion, which differs from usability testing, which only engages end-users with the completed version of prototypes These structured methods promote consideration of the motivations and concerns of real- world users across the design process, limiting time and resource wastage on creating tools that are not relevant or acceptable to the target population. 77 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES APPENDIX G SUMMARY OF RECOMMENDATIONS # CURRENT SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE DIGITAL ENVIRONMENT R1 Need for leadership and ownership Restructure the IT department within MOH and expand their Positioning of the MoH as the Start  IT Department of digital health strategy role beyond ICT maintenance to promote inclusive digital guidance, coordination, and Now Ministry of Health health policies and strategies across internal and external regulatory body on digital  Ministry of Finance stakeholders. Assign a dedicated budget for digital health with health defined objectives and priorities; align and funnel investments to the right interventions; provide adequate skill mixes; and evaluate interventions. R2 Extensive use of mobile, however Enrich the Lesotho ICT policy 2021 by conducting a health Improvement of connectivity Start  Ministry of Health mobile coverage and internet sector infrastructure assessment. Conduct a sectoral and electricity supply to Now  Ministry of connectivity is not equally assessment of infrastructure and connectivity to implement some ensure the functioning of Communications, distributed, unstable electricity of the recommendations made by the Lesotho ICT policy 2021 systems and the Science, and supply (currently in draft form). implementation of digital Technology health interventions 78 R3 Few courses that can provide digital Collaborate with the Ministry of Education and Training to Creation of a pre-trained cadre Start  Ministry of Health health skills at levels of pre/in- implement pre-service education of health professionals to assist the work of the MoH. Next  Ministry of Education training and health workers on digital health, as well in service Potential to leverage regional and Training health professionals. The curriculum should include topics in knowledge by coordinating health informatics, data science for health care, development with other digital health and implementation of digital health interventions, and capacity-building initiatives or entrepreneurship to create a pre-trained cadre to assist the work through the digital health hub of the MoH. Leverage regional knowledge by coordinating with (R4). other digital health capacity-building initiatives. Table continued on page 79 SUMMARY OF RECOMMENDATIONS (continued) # CURRENT SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE DIGITAL ENVIRONMENT (continued) R4 Lack of interoperability with other Promote digital health within the broader e-government Develop policies and Start All government sectors that are connected to health context to enhance the digital economy, including guidelines for facilitating the Next (i.e., education, housing, promoting digital ID. The African Union’s Agenda 2063, ratified dialogue and policy making transportation), limiting a holistic by all African countries, aims to ensure that “99.9% of people in around potential investments, perspective of patients Africa have a digital legal identity as part of a civil registration research centers, and process by 2030.” The MoH must coordinate with other coordination with universities governmental bodies to implement digital ID to empower for local development of digital patients by linking patient information across facilities. health to enhance the digital economy R5 Limited human resources as people Formalize digital health collaboration with countries within Economies of scale and Start  Ministry of Health move to neighboring countries to the SADC region to form a regional digital health hub, like human resources, skills, Later  AU specific Regional study and work Digital REACH Initiative proposed by USAID for the East knowledge, and better Economic Africa Community. Lesotho could coordinate efforts and practices to improve readiness Communities collaborate with neighboring countries through a regional digital to manage future events,  AU health hub, that will facilitate sharing of human resources, skills, because Lesotho is fully knowledge, and better practices to improve preparedness and dependent on South Africa 79 resilience for future health events such as pandemics. ARCHITECTURE AND DATA R6 Nascent development safeguards Conduct a cybersecurity assessment to improve Creation of the necessary Start  Ministry of Health and preparedness for digitalization cybersecurity and data privacy. Provide technical assistance safeguards to protect the Now  Ministry of to develop policies and guidelines for data privacy, cybersecurity, privacy and security of data Communications, and data transfer to reduce vulnerability to cyber-attacks that and systems and avoid the Science, and could disrupt the provision of care or jeopardize the privacy of disruption of health care Technology Ministry patients’ data. delivery of Justice R7 Limited Standard and operating Develop health data governance legislation. Develop data Improved interoperability Start  Ministry of Health procedures. Lack of standards for governance legislation and standards and define data ownership, between the MoH and Next  Ministry of Justice, data governance data transparency, data governance, and data management partners and information Human Rights & sharing information rules within the health information exchange transfer from facilities and Correctional architecture. partner’s programs into the Services MoH Table continued on page 80 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES SUMMARY OF RECOMMENDATIONS (continued) # CURRENT SITUATION RECOMMENDATION IMPACT PHASING RESPONSIBLE ARCHITECTURE AND DATA (continued) R8 Limited interoperability between Expand the health information exchange architecture to Facilitation of continuity of Start  Ministry of Health health facilities and between MoH build a digital health platform (infostructure). Apply the care by sharing data among Next  Partners and partners recent WHO guideline “Building a Digital Information users, health care providers, Infrastructure (Infostructure) for Health” to build a digital health health systems managers, platform using accepted standards and connect with other MoH and health data services applications, such as pharmacy systems, DHIS-2, and future human resources and logistics management applications. ANALYTICS R9 Inefficient use of data systems to Design and implement a health facility report card based on Creation of evidence-based Start Ministry of Health monitor, evaluate, analyze, and selected indicators for quality improvement. Indicators could inputs to support decision- Now improve health care include service delivery, patient satisfaction, resources, and wait making and resource times to provide insight and transparency regarding the quality of allocation care at each health facility. R10 Lack of targeted digital health Commission an assessment of primary health care Matching of digital health Start Ministry of Health interventions challenges to identify areas that can be improved with interventions to primary care Now 80 digital health mechanisms. To be effective and impactful, challenges and generation of digital health interventions or applications should respond impactful outcomes directly to primary care challenges that can be identified through assessments like the World Bank’s vital signs profile for primary health care performance improvement (PHCPI). R11 Data is being collected however, Commission a data quality assessment. As part of the effort Improved decision making Start Ministry of Health quality is low and not always to strengthen surveillance and data collection, the World Bank is using timely and complete Now reliable currently conducting a process mining analysis from data data and information collection to data reporting and analysis. This can contribute to a more extensive data quality assessment quality across the health care sector. Table continued on page 81 SUMMARY OF RECOMMENDATIONS (continued) # CURRENT SITUATION RECOMMENDATION IMPACT PHASING  RESPONSIBLE APPLICATIONS R12 Lack of a costed implementation Design a prioritized and costed plan for digital health Completion of a costed Start  Ministry of Health plan of digital health applications. This plan should determine which interventions implementation plan Now  Partners interventions/applications are relevant, provide an estimate of costs and benefits, assign responsible parties, and provide a clear monitoring and evaluation plan. The WHO Digital implementation investment guide (DIIG) could be a valuable resource to guide this work. R13 Fragmentation and dependency on Commission technical assistance to support public-private Lesotho currently enjoys Start Ministry of Health partners for digital health partnerships (PPP) and service level agreements (SLA) for significant public investment. Now development digital health interventions. SLAs could address the lack of The current global discussions Lack of private investment and digital health skills and skilled resources in the short term. These about PPPs could generate entrepreneurship should be accompanied by a mid-term strategy to create skilled, enough incentive to attract in-house resources. Coordination with WHO and IFC could private sector investment in support this activity. the country. 81 R14 Limited number of digital health Design a plan to scale up e-Register gradually over the next Provision of comprehensive Start Ministry of Health interventions at community level three years to transform all existing health programs and care for all Next Limited programs within e-Register into a comprehensive EMR. Expand the e-Register to include aspects such as family planning, chronic diseases, children’s health, among others to assure comprehensive care for all. R15 Lack of impact evaluation of digital Establish an innovation testing environment for the various Generation of evidence, Start  Ministry of Health health investments interventions and evaluate impact and feasibility. Testing measurement of social Next  Private sector environments, such as an innovation and regulatory sandbox or response, elimination of failed  Universities living lab, can provide a framework to test solutions in a interventions, and reduction of responsible, monitored, and real-world environment. future implementation costs. R16 Lack of evidence on the cost and Commission feasibility and economic evaluation studies of Creation of evidence to guide Start  Ministry of Health effectiveness of digital health priority digital health interventions. Build evidence on the the MoH on future Later  Partners interventions cost-effectiveness and cost benefit of digital health interventions investments such as eRegister, DHIS-2, ECHO to prioritize future investment. APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES APPENDIX H SUMMARY OF PRIORITY DIGITAL HEALTH INTERVENTIONS BY HEALTH SYSTEM CHALLENGE Interventions are grouped according to the WHO Classification of Digital Health Interventions, based on system challenges, clients, digital health interventions and system category. Table H1 summarizes each digital health application in relation to the health system challenge it aims to resolve. Table H.2 offers examples of the applications used for each health system challenge identified. Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge DIGITAL HEALTH WHO WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER HEALTH INTERVENTION SYSTEM CATEGORY Surveillance and public health data 4.1.4 Automated analysis collection, processing, and quality Disease outbreak 1.2 Delayed Data collection, of data to generate Emergency check are time consuming, affecting notifications, early reporting of Data services management, new information or I response timely decision making. Due to the high warning events and use develop future system prevalence of communicable diseases, applications projections early detection of cases is fundamental. 82 Manual data processing is vulnerable to Shared health Rule-based 1.3 Lack of errors and currently, there are Data collection, records and systems in EMR for 4.1.2 Data storage and quality/reliable discrepancies among data points (e.g., Data services management, X health data entering, aggregation data a woman-specific disease should not and use information integrity, and quality be registered for a man) repositories INFORMATION 1.1.4 Transmit diagnostic results, or Client Targeted client Results notification Clients communicate the D communication communication Patients are not notified of their results availability of results, system or appointments (e.g., COVID-19 to client(s) 1.5 Lack of access results). In addition, limited e-Register to information 2.2.1 Longitudinal tracking Electronic data (only TB and HIV) does not Expansion of e- Health system Client health or data of clients’ health H Medical provide comprehensive information to Register providers Records status and services Record the health care worker Implementation of Data collection, GIS, HMIS 4.1.3 Data synthesis and intelligent Data services management, Various surveillance visualization dashboards and use system Table continued on page 83 Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge (continued) DIGITAL HEALTH WHO WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER HEALTH INTERVENTION SYSTEM CATEGORY 2.4.1 Consultations 2.1 Insufficient between remote supply of Y Telemedicine clients and health commodities The fragile financial situation of Lesotho care providers affects the resources provided to the health care sector. This also affects the 2.4.2 Remote monitoring of 2.2 Insufficient Telemedicine for supply of equipment and qualified client health or supply of follow up with TB Y Telemedicine health care workers, the ability to diagnostic data by the services and HIV patients, Health system AVAILABILITY provide the same quality of health Telemedicine health care provider telecare for initial providers 2.3 Insufficient services consistently to every citizen 2.4.3 Transmission of triage and mild supply of and region. The capacity for testing, medical data to the Y Telemedicine cases equipment laboratory diagnostics, medical health care provider consultation, infection control, and 2.4 Insufficient critical care is weak. 2.4.4 Consultations for supply of case management Y Telemedicine qualified health between health care workers providers 83 Patients in Lesotho cannot schedule On-demand Appointment Client appointments online, and at health information 1.6.1 Client search for scheduling through Clients D communication facilities, appointments are managed services to health information SMS system manually using a registration book. This clients 3.1 Poor patient affects the experience of the patient, QUALITY experience who must, therefore, remember Health worker appointments. Moreover, at the facility Module for tracking 2.7.2 Scheduling of the Health system activity Facility management level, the patients with appointments no-shows in e- health care provider's K providers planning and information systems may not be prioritized over walk-in Register activities scheduling patients Table continued on page 84 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge (continued) DIGITAL HEALTH WHO WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER HEALTH INTERVENTION SYSTEM CATEGORY 2.4.4 Consultations for Expansion of Health system case management telementoring Telemedicine Y Telemedicine providers between health care support providers 3.2 Insufficient Lack of qualified health workers. Nurse- Expansion of Health care 2.8.1 Provision of training health worker Health system Learning and training driven health facilities telementoring provider to health care S competence providers system support training providers Expansion of Health care 2.8.2 Assessing the Health system Learning and training telementoring provider capacity of health S providers system support training care provider(s) Telemedicine Clients ‒ ‒ Y Telemedicine QUALITY Health worker Module for tracking 2.7.2 Scheduling of the (continued) Health system activity Facility management no-shows in e- health care provider's K providers planning and information systems 84 Register activities scheduling Lack of interoperability between health Client health 2.2.2 Management of Electronic Medical 3.5 Insufficient facilities and hospitals, and a limited records client’s clinical H Record continuity of health information exchange, do not records care enable follow-up across the patient Expansion of Health system e-Register providers Client health 2.2.4 Routine health journey, reducing the quality of care. records indicator data Electronic Medical H collection and Record management Implementation of 2.6.1 Coordination of Data interchange Health system Referral digital referral emergency response G interoperability and providers coordination system and transport accessibility Table continued on page 85 Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge (continued) DIGITAL HEALTH WHO WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER HEALTH INTERVENTION SYSTEM CATEGORY On-demand Appointment Client Due to the distance between health information 1.6.1 Client search for scheduling through Clients D communication facilities and homes (especially rural services to health information SMS system 5.1 Low demand areas), health care personnel often clients for services intervene once cases are critical 1.2.1 Transmission of instead of using preventive health Untargeted Health promotion untargeted health measures to limit the severity of cases Clients client C Client applications messaging information to an communication undefined population The mountainous geography of the 5.2 Geographic country hampers certain populations’ Telemedicine Clients ‒ ‒ Y Telemedicine inaccessibility ability to reach health facilities 1.1.3 Transmission of Client UTILIZATION Appointment Targeted client Clients targeted alerts and D communication reminders communication reminders to client(s) system 85 Adherence to treatment plans is 1.4.1 Access by the client Client Medication Personal health fundamental to reduce the severity of Clients to own medical D communication management tracking 5.3 Minimal communicable diseases such as HIV records system adherence to and TB. The lack of health literacy and 1.2.1 Transmission of treatment plans the distance to health facilities impede Untargeted Health promotion untargeted health follow-up of treatments and monitoring Clients client C Client applications messaging information to an of adherence. communication undefined population Nudge and gaming 1.4.2 Self-monitoring of Personal health applications for Clients health or diagnostic C Client applications tracking behavioral change data by client Table continued on page 86 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge (continued) DIGITAL HEALTH WHO WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: HEALTH INTERVENTION SYSTEM CATEGORY SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER Adherence to treatment plans is 1.1.3 Transmission of Client Appointment Targeted client fundamental to reduce the severity of Clients targeted alerts and D communication reminders communication communicable diseases such as HIV reminders to client(s) system UTILIZATION 5.4 Loss to follow and TB. The lack of health literacy and Health worker (continued) up Module for tracking 2.7.2 Scheduling of the the distance to health facilities impede Health system activity Facility management follow-up of treatments and monitoring no-shows in e- health care provider's K providers planning and information systems of adherence. Register activities scheduling There are limited standard operation 2.6.2 Management of 6.1 Inadequate procedures at health facilities. Most of Implementation of referrals between Data interchange Health system Referral workflow the registries are paper based and, in digital referral points of service G interoperability and providers coordination management many cases, folders and patient system within the health accessibility records are lost. sector 2.6.3 Management of 6.2 Lack of or Referrals are registered in the Implementation of Data interchange Health system Referral referrals between inappropriate BOKANA, a paper booklet maintained digital referral G interoperability and providers coordination health and other 86 referrals by each patient. system accessibility sectors The lack of timely information affects Disease outbreak 6.3 Poor planning Public health 3.3.1 Notification of public Client EFFICIENCY the planning and coordination of notifications, early Health System and event health events from D communication resources. Lesotho's capacity for warning Managers coordination notifications point of diagnosis system pandemic preparedness is limited. applications 2.6.3 Management of Implementation of Data interchange Health system Referral referrals between The lack of timely information and digital referral G interoperability and providers coordination health and other 6.4 Delayed interoperability does not permit effective system sectors accessibility provision of tracking of cases, which delays the care provision of care and increases the Disease outbreak Public health 3.3.1 Notification of public Client severity of cases that can be managed. notifications, early Health System event health events from D communication warning Managers notifications point of diagnosis system applications Table continued on page 87 Appendix table H.1 Priority Digital Health Interventions (applications) by Health System Challenge (continued) DIGITAL HEALTH WHO WHO CLASSIFICATION: HEALTH HEALTH SYSTEM APPLICATIONS/ CLASSIFICATION: WHO CLASSIFICATION: DIGITAL WHO CLASSIFICATION: SYSTEM CHALLENGES CHALLENGE INTERVENTIONS PRIMARY USER HEALTH INTERVENTION SYSTEM CATEGORY Health worker Module for tracking 2.7.2 Scheduling of the Health system activity Facility management no-shows in e- health care provider's K Lesotho has many manual processes providers planning and information systems 7.1 High cost of Register activities (from patient registration and data scheduling manual collection to data quality verification and 2.6.3 Management of processes Implementation of Data interchange administrative processes). Health system Referral referrals between digital referral G interoperability and providers coordination health and other system accessibility sectors COST Health worker Module for tracking 2.7.2 Scheduling of the As referrals, appointments, registries, Health system activity Facility management no-shows in e- health care provider's K 7.2 Lack of and supplies are not completely providers planning and information systems Register activities effective digitalized, the government cannot scheduling resource effectively allocate resources, which Automatic medical Health care allocation affects the supply at health facilities and triage applications 2.3.3 Screening of clients Health system provider Facility management the quality of care. by risk or other health K based on providers decision information systems 87 status comparable cases support The high prevalence of communicable and non-communicable diseases and 1.2.1 Transmission of 8.1 Insufficient Untargeted significant malnutrition can be Health promotion untargeted health ACCOUNTABILITY patient Clients client C Client applications controlled if patients are engaged and messaging information to an engagement communication there is strong communication between undefined population the policy maker and the end-user. APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table H.2 Examples of Digital Health Applications SELECT INTERVENTIONS FOR LESOTHO ACCORDING TO THE WHO CLASSIFICATION OF EXAMPLES DIGITAL HEALTH INTERVENTIONS (EXTRACTED FROM THE WHO CLASSIFICATION OF DIGITAL HEALTH INTERVENTIONS) TARGETED CLIENT COMMUNICATION 1.1.3 Transmission of targeted alerts and reminders  EngageTB: “Once a client has been confirmed as TB positive, the Lab Technicians will register the client back into the application to client(s) and enable the client to receive reminders about Directly Observed Therapy (DOT).”  mTIKA: “...sends SMS reminders to families when their children are due for immunization services.”  Moby App: “sends automated SMS reminders to clients, reminding them of upcoming appointments, missed appointments, and approaching delivery dates so women can prepare to deliver in a health facility.”  Wired Mothers: “Women receive appointment reminders and educational messaging and can call their primary care providers to discuss non-acute issues.” 1.1.4 Transmit diagnostic results, or communicate the  txtAlert: “This version of txtAlert delivers CD4 count results to patients who have been tested for HIV but who may not return to the availability of results, to client(s) clinic to collect their CD4 count results” UNTARGETED CLIENT COMMUNICATION 1.2.1 Transmission of untargeted health information  WAHA Maternal Health mHealth Program: “Two SMS campaigns were launched, targeting the inhabitants of the Tambacounda to an undefined population district... The second campaign targets all people, so that they are regularly informed of available medical services within the district.” PERSONAL HEALTH TRACKING 88 1.4.1 Access by the client to own medical records  Digital Weighing Card: “This project is therefore seeking to provide a digital copy of every child weighing card, such that it can be accessed via mobile phone whenever needed and updated by community health workers at any time.” 1.4.2 Self-monitoring of health or diagnostic  Wearables and fitness trackers: “track every part of your day—including activity, exercise, food, weight, and sleep.” data by client  Medopad Patient Monitoring: “monitor vital signs, log symptoms, share information with your care providers and more.” ON-DEMAND INFORMATION SERVICES TO CLIENTS 1.6.1 Client search for health information  Hesperian Health Wiki: “An online source of clear, actionable, and thorough health information accessible via computer or mobile device.”  EngageTB: “The software enables clients to do TB self-screening and access basic health information related to TB via short messages (SMS) through their phones. Clients send the code “TB” to a network neutral toll-free short code and a list of health facilities that can conduct laboratory tests to confirm TB status.”  m4RH: “A set of text messages on family planning methods that users in can access via their mobile phones.” Table continued on page 89 Appendix table H.2 Examples of Digital Health Applications (continued) SELECT INTERVENTIONS FOR LESOTHO ACCORDING TO THE WHO CLASSIFICATION OF DIGITAL HEALTH EXAMPLES INTERVENTIONS (EXTRACTED FROM THE WHO CLASSIFICATION OF DIGITAL HEALTH INTERVENTIONS) CLIENT HEALTH RECORDS 2.2.1 Longitudinal tracking of clients’ health status and  MomConnect: “Register each pregnancy at a government health facility” services  iCMM: “The first component of the iCMM application captures all elements of the village register used by the HSA. The application has built-in functionalities that enable HSAs to register children between the ages of 2 and 59 months only and adhere to standard protocols.” 2.2.2 Management of client’s clinical records  OpenMedical Record System (OpenMRS): “a software platform and reference application to design a customized medical records system.”  Epic Systems: “provide a full picture of health and membership information for your members and a secure web portal for providers to interact with and view managed care information.” 2.2.4 Routine health indicator data collection and  Catholic Relief Services (CRS) Senegal [CommCare] mHealth Pilot: “The app was developed to collect data on childhood management illnesses and manage child diarrhea cases; it is accessible via a central database.”  SEDA Automated Health Data Exchange System (SEDA): “Data [facility-level indicators] are aggregated in a centralized, web-based system to visualize and manage decision support. Aggregate-level data reported to the mobile system from health facilities are automatically uploaded into DHIS-2 once validated.” 89  DHIS-2: “used as a national health information system for data management and analysis and health program monitoring and evaluation.” HEALTH CARE PROVIDER DECISION SUPPORT 2.3.3 Screening of clients by risk or other health status  OpenSRP: “contains electronic forms with embedded logic and decision support, including checklists and algorithms for risk assessment.”  Emergency Triage Assessment and Treatment (ETAT): “Using the app with the ETAT protocol, health workers scan the queues at the health centers, assessing each child for the appropriate level of acuity and identifying children who need immediate assessment.”  ePartogram: “syncs data within a facility and automatically prioritizes laboring clients based on clinical algorithms, helping supervisors allocate staffing appropriately.”  CommCare Mobile Job Aid for Sahiyas: “It is built on a complex decision- and logic-processing platform that can help these CHWs deliver timely services.” Table continued on page 90 APPENDICES TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table H.2 Examples of Digital Health Applications (continued) SELECT INTERVENTIONS FOR LESOTHO ACCORDING TO THE WHO CLASSIFICATION OF DIGITAL HEALTH EXAMPLES INTERVENTIONS (EXTRACTED FROM THE WHO CLASSIFICATION OF DIGITAL HEALTH INTERVENTIONS) TELEMEDICINE 2.4.1 Consultations between remote clients and health care  VillageReach Chipatala cha pa Foni (CCPF): “A toll-free health hotline that is staffed by trained health workers who provide providers information, advice, and referrals over the phone.”  Ligne Verte: “By dialing a toll-free number, callers can speak to a trained educator and get accurate information about birth spacing, the correct use of family planning methods, how to avoid unwanted pregnancies, and how to locate the nearest partner clinic.” 2.4.2 Remote monitoring of client health or diagnostic data  Body Sensor Networks for Mobile Health Monitoring: “patients’ biosignals are measured with body-worn sensors that by health care provider communicate wirelessly with a handheld device. Alarms and biosignals can be transmitted over wireless communication links to a remote location, and a remote health professional can view the biosignals via a web application.” 2.4.3 Transmission of medical data to the health care  Africa Teledermatology Project: “The Africa Teledermatology Project operates in six African countries, using cameras and provider laptop PCs to capture and send images of patients to specialists in other African countries, Austria, and the United States, providing diagnostic and treatment support to local physicians, dermatologists, and health care workers in hospitals and clinics in underserved regions." 2.4.4 Consultations for case management between health  Mobile-based Early Detection and Prevention of Oral Cancer (mEPOC): “Information collected on the mobile phones is 90 care providers uploaded to OpenMRS. A specialist in a remote location sends the recommendation through SMS.”  Peek Vision: “A health worker with minimal training can use Peek to gather detailed clinical information. Images are graded and patients diagnosed, either through an automated process or via cascading of digital images to a network of experts around the world.” REFERRAL COORDINATION 2.6.1 Coordination of emergency response and transport  mHealth for Safer Deliveries: “use text or voice communication to notify a health facility that a woman is in transit to ensure the facility is prepared.” 2.6.2 Management of referrals between points of service  Mobile-based Early Detection and Prevention of Oral Cancer (mEPOC): “CHWs can communicate with the specialists within the health sector through open Medical Record System (OpenMRS) and refer patients for treatment in a timely manner.”  ePartogram: “It also strengthens the referral pathway between peripheral and referral facilities by enabling electronic transmission of data between facilities” Table continued on page 91 Appendix table H.2 Examples of Digital Health Applications (continued) SELECT INTERVENTIONS FOR LESOTHO ACCORDING TO THE WHO CLASSIFICATION OF DIGITAL HEALTH EXAMPLES INTERVENTIONS (EXTRACTED FROM THE WHO CLASSIFICATION OF DIGITAL HEALTH INTERVENTIONS) REFERRAL COORDINATION (continued) 2.6.3 Management of referrals between health and other  Unnamed project: Referrals do not only take place within the health sector, but also between the health sector and other non- sectors health services. For example, in cases of gender-based violence, referrals may be provided by social services, police, justice services and health services. In the case of traffic accidents, referrals are needed from police, emergency services, and health services. In cases of malnutrition, referrals may be needed from health and food support services. Where health and poverty and closely inter-related, referrals may be needed to provide economic strengthening, social services, and health services. Digital systems may offer features to support and track these referrals. HEALTH WORKER ACTIVITY PLANNING AND SCHEDULING 2.7.2 Scheduling of the health care provider's activities  mCARE: “integrated mobile phone and server-based software system for CHWs that helps them digitally manage their daily workflow.”  CommCare for home-based care: “provides CHWs a checklist of activities which are expected to be performed during each home visit, as well as reminders of appointments.” HEALTH CARE PROVIDER TRAINING 2.8.1 Provision of training to health care providers  Projecting Health: “Frontline health care workers are equipped with educational videos to conduct video screening and lead 91 group discussions on issues raised in the videos.”  iDEA: Interactive Distance Education Application: “Providing health workers with mobile-based video instruction and reference materials”  Safe Delivery App: “The app contains three animated clinical instruction films...can also be used as a reference tool during clinical work”  OppiaMobile: “mobile learning platform for delivering learning content, videos, and quizzes.” Mobile Academy: “an interactive voice response (IVR) training course designed to refresh CHWs’ knowledge of simple steps families can take to improve the health of mothers and babies and to improve their ability to clearly communicate them.” 2.8.2 Assessing the capacity of health care provider(s)  Safe Delivery App: “The app features push messages with quizzes prompting the health worker to use the application to update their knowledge.” PUBLIC HEALTH EVENT NOTIFICATION 3.3.1 Notification of public health events from point of  mSOS Ebola (KEMRI Laboratory module): “Results of laboratory confirmation of the patient serum samples were updated diagnosis using the mSOS Ebola web portal, and text messages were automatically delivered to senior management and policy makers at the MoH.” GXAlert: “Automatically send SMS texts or email alerts to MoH officials when a new MDR-positive or RIF-positive case is APPENDICES detected.” Table continued on page 92 TRANSFORMING HEALTH CARE IN LESOTHO: USING DIGITAL HEALTH TO OVERCOME HEALTH SYSTEM CHALLENGES Appendix table H.2 Examples of Digital Health Applications (continued) SELECT INTERVENTIONS FOR LESOTHO ACCORDING TO THE WHO CLASSIFICATION OF DIGITAL HEALTH EXAMPLES INTERVENTIONS (EXTRACTED FROM THE WHO CLASSIFICATION OF DIGITAL HEALTH INTERVENTIONS) DATA COLLECTION, MANAGEMENT AND USE 4.1.2 Data storage and aggregation  Anesthesiological Data Warehouse Project: “A web interface that will allow users to input and access pre-, peri- and post- operative anesthesiology data.” 4.1.3 Data synthesis and visualization  cStock: “District- and central-level managers could monitor supply chain performance using over 10 indicators displayed on a web-based dashboard.”  DHIS-2: “Get the complete overview through the pivot table feature, spot trends in your data with charting, and visualize your geographical data using the GIS function.” 4.1.4 Automated analysis of data to generate new  Simplified, Effective, Labour Monitoring-to-Action (SELMA) tool: “Prediction models will be developed to identify women at information or develop future projections risk of intrapartum-related perinatal death or morbidity (primary outcomes) throughout the course of labor.” 92 93