Abstract

Global digital technology advances offer the potential to enhance primary health care (PHC) quality, reach, and efficiency, driving toward universal health coverage (UHC). This scoping review explored how digital health solutions aid PHC delivery and UHC realization by examining the context, mechanisms, and outcomes of eHealth interventions. A comprehensive literature search was conducted, capturing qualitative and quantitative studies, process evaluations, and systematic or scoping reviews. Our analysis of 65 articles revealed that a well-functioning digital ecosystem—featuring adaptable, interoperable digital tools, robust Information and Communications Technology foundations, and enabling environments—is pivotal for eHealth interventions’ success. Facilities with better digital literacy, motivated staff, and adequate funding demonstrated a higher adoption of eHealth technologies, leading to improved, coordinated service delivery and higher patient satisfaction. However, eHealth’s potential is often restricted by existing socio-cultural norms, geographical inequities in technology access, and digital literacy disparities. Our review underscores the importance of considering the digital ecosystem’s readiness, user behavior, broader health system requirements, and PHC capacity for adopting digital solutions while assessing digital health interventions’ impact.

Keywords: 

digital health; mHealth; eHealth; primary healthcare; universal health coverage

1. Introduction

The 2030 Sustainable Development Goals emphasize having everyone receive the quality health services they need without any financial hardship [1]. Achieving universal health coverage (UHC) entails making significant progress on efficient, accessible, quality and equitable health services, while ensuring financial risk protection [2]. Primary health care (PHC), which first came to the fore with the 1978 Alma Ata declaration [3], provides the programmatic engine for UHC in most contexts and countries [4]. While the COVID-19 pandemic has resulted in global disruptions in the provision of essential health services including those provided at the PHC level [5], the public health measures put in place (e.g., lockdown, social distancing) have forced to shift the paradigm of service delivery model and provided an opportunity to accelerate the adoption and implementation of digital health solutions [6].

Digital health is an overarching term that comprises eHealth (e.g., telemonitoring, tele- and video- consultations, mHealth, electronic health records) and emerging technologies, including the use of computing sciences in the fields of artificial intelligence, big data, and genomics. The World Health Organization (WHO) defined electronic health (eHealth) as the use of information and communications technology (ICT) in support of health and health-related fields, including health care services, health surveillance, health literature, and health education, knowledge, and research [7].

The digital health infrastructure and its integration into PHC services vary greatly among countries, often influenced by the economic status, health priorities, and technological advancements of a region. Notably, the increasing ubiquity of mobile devices and internet connectivity offers a unique opportunity to leverage digital health solutions even in resource-constrained settings. Recent data indicate that more than 8 in 10 people in developing countries own a mobile phone, and nearly half the global population uses the Internet [7,8]. This widespread accessibility to digital platforms underscores the potential reach and impact of digital health interventions. Several countries have proactively responded to this rapidly evolving digital landscape. Approximately 87% of the World Health Organization member states have developed national policies or strategies geared toward eHealth, telemedicine, or the broader domain of digital health [7]. However, the degree of implementation and maturity of these strategies differ widely. While some countries boast advanced digital health ecosystems with comprehensive integration of electronic health records and telemedicine services, others are in the nascent stages, piloting innovative solutions tailored to their unique contexts. Factors such as internet penetration, mobile device accessibility, and data protection regulations play a pivotal role in shaping these digital health strategies. Recognizing the transformative potential of digital health, many international organizations and stakeholders are collaborating to bolster the digital health capacities of countries, especially in low- and middle-income regions.

The accelerated adoption of eHealth and mHealth platforms and the rapid change in the access to digital technologies have created a tremendous opportunity to expand the reach, quality, and efficiency of PHC service delivery and achieve UHC. Health systems can leverage advances in ICT to improve and maintain the continuity of service delivery post-COVID-19, such as by strengthening health management information systems and optimizing the functionality of shared electronic health records. Digital technologies also play an important role in advancing the core PHC tenet of a people-centered and integrated health service delivery model and community empowerment by improving information flows between patients and health workers, thereby shifting the nature of the patient–provider relationship. The WHO recently published a framework of e-Health for improved health service delivery [9], describing the potential contributions of e-Health to each of the health system attributes (i.e., service quality, efficiency, equity, accountability, sustainability, and resilience) at different levels—the individual, the service provider, the health-care organization, and the overall health system. In addition, newly emerging technologies, such as artificial intelligence and drones, have opened exciting possibilities and new avenues to improve the quality and accessibility of PHC services. However, without proper regulation and legislation, digital technologies may result in potentially harmful effects (e.g., mental illness in children associated with the digital revolution) and potential for worsening existing inequities [10].

In response to the 2018 World Health Assembly Resolution on Digital Health, the WHO conducted a review of the evidence for digital health interventions. While this review provided data regarding the impact of digital technologies on strengthening the overall health system, it was limited to a few selected interventions and did not provide insight on what works for whom and under what circumstances in the context of PHC [11]. This scoping review aimed to explore the underlying contexts and mechanisms in which digital health solutions contribute to improved PHC service delivery and the realization of UHC. We employed the WHO’s Framework of e-Health for improved health service delivery as an analytical framework to answer the following key questions: (i) Which eHealth solutions are adopted or implemented to increase access to PHC services and achieve UHC [8]? (ii) What is the role of contextual factors (i.e., why, how, for whom, and in what circumstances does it work?).

2. Materials and Methods

We carried out a comprehensive review of both published research and grey literature detailing digital health solutions related to PHC and UHC. This analysis was grounded in the PRISMA-ScR guidelines tailored for scoping reviews [12] (refer to Supplementary Table S1 for details). A detailed overview of our approach is available in Erku et al. [13].

2.1. Data Sources and Search Strategy

Six online databases (PubMed, CINAHL, Web of Science, Cochrane Library, EMBASE, and Google Scholar) were explored, in addition to grey literature sources (PDQ-Evidence and mHealth Database), to find studies discussing the background, strategies, and results of eHealth strategies within PHC environments. Additionally, we undertook supplementary methods such as examining references and citations of the studies we found and using generic online searches to include potential articles missed in our initial database exploration. The search terms were formulated around three central themes: digital health, primary health care, and universal health coverage. These terms were adapted to fit the specific criteria of each database (for more details, refer to Supplementary Table S2). The use of Boolean operators and truncations was tailored based on the specific database. We considered articles written in English from the time the databases were created until December 2022 and we refreshed our search in August 2023. We did not set any restrictions regarding the publication period or the country of origin.

2.2. Eligibility Screening

We included editorials, opinion/position pieces, commentaries, process evaluations, qualitative and quantitative studies, program manuals, and systematic reviews that reported data on (i) the effectiveness eHealth solutions in improving PHC service delivery and UHC and (ii) contextual factors affecting the acceptability, feasibility, and implementation of eHealth solutions. We broadly categorized digital health solutions modalities into (i) technologies used to monitor, track, and inform health (e.g., mobile devices, such as smartphones and tablets, and clinical devices, mobile sensors, wearables, apps, social media), (ii) technologies used to enable health communication and provision of health services at a distance (e.g., client-to-provider and provider-to-provider telemedicine, targeted client communication), (iii) technologies used to collect, manage, and use health data (e.g., electronic medical records, electronic health records, artificial) [14]. We also included all system-level eHealth solutions targeting various levers of PHC and those modalities that have functions that cut across multiple health system attributes (e.g., health worker decision support tools, e-learning, stock notification and management tools, artificial intelligence). We considered all forms of delivery channels, including digital applications, SMS text messaging, voice calls, and interactive voice responses.

We excluded (i) eHealth solutions that were tailored for a specific health issue, (ii) conference notes or thesis overviews where the full text was not available. The identified articles were moved to COVIDENCE (by Veritas Health Innovation Ltd., Melbourne, Australia). Two reviewers separately checked all the titles, summaries, and the full content of the articles to ensure they fit our criteria. If the reviewers had different views, they discussed them until they agreed. Our search process is detailed in Figure 1. We used the Mixed Methods Appraisal Tool (MMAT) [15] to assess the quality of the studies we included, be they qualitative, quantitative, or a combination of both. This was to help us better understand the results based on the study’s quality, not to decide which studies to include.

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

2.3. Data Extraction and Synthesis

Information from each article was gathered and analyzed using both deductive and inductive methods. This process of data extraction was recurring, involving continuous discussions and agreements within the research team regarding the approach to data extraction and the initial analytical structure. We collected the study features into a table to provide a succinct summary of the digital health solutions that were included, focusing on their context, methods, and results. We recorded details about the study like the authors, publication year, objectives, design, and participant traits, as well as the main conclusions such as the goals, kinds, and scope of eHealth initiatives and their effects, including the ways eHealth affected PHC aspects and results related to UHC.

The extracted data were categorized into and analyzed as what caused an outcome, through which mechanism, and under which context [16]. Digital health interventions may work in one context but not in others, and as such, an outcome is measured as the context and mechanisms in which the program is implemented. In this review, the concept of “context” entails the relational, system-level, and dynamic features that shaped the mechanisms through which a digital health intervention worked and whether the country of the digital health implementation was a low-, middle-, or high-income country. Mechanisms are “underlying entities, processes, or structures which operate in particular contexts to generate outcomes of interest” [17]. Outcomes from implementing digital health solutions are measured as the impact on achieving UHC through improving PHC service delivery and accessibility. When research conducted in similar settings or contexts showed varying results, we combined and analyzed the evidence to pinpoint potential reasons for the differences. Additionally, we compared evidence when data on digital health solutions from one study provided insights into the outcomes mentioned in another study.

3. Results

After excluding duplicate entries and publications that did not fulfill the selection criteria, we selected 65 articles from 16 different countries. This collection included systematic and scoping reviews [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32], secondary analyses of trial and quasi-experimental data [33,34,35], quantitative surveys [7,36,37,38,39,40,41], qualitative studies [14,42,43,44,45,46,47,48], mixed methods studies [49,50,51,52,53,54,55,56,57,58,59,60], program evaluations, case studies, and opinion pieces [61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79]. The included studies’ characteristics are summarized in the Supplementary Table S3.

All cross-sectional studies we reviewed scored either average (score ≥ 65%) or above (score ≥ 75%) based on the Mixed Methods Appraisal Tool. In the qualitative studies, the data were obtained through detailed interviews, focus group discussions, or a mix of the two. Each study explicitly stated its research objectives and clarified where its data came from, whether from participants or specific recruitment sites. However, many studies did not provide clear insights into the researchers’ roles or the specifics of the interview questions. In the next section, we outline how digital health impacts the core qualities of a high-functioning health system and we explore the contexts and strategies that bring about these outcomes.

3.1. eHealth Foundations for Improved PHC Service Delivery

Digital health solutions are potential tools for strengthening PHC and improving care delivery. However, they are only as good as the foundations, (pre)existing services, and governance systems that are put in place. There is a significant difference among and within countries in terms of eHealth adoption and the existing digital ecosystem. In countries with strong ICT foundations, such as Australia, Canada, the United Kingdom, and the United States, PHC practice transformed and responded rapidly to the COVID-19 pandemic by instituting telehealth, and electronic records enabled change [57,63].

A detailed scoping review by Ndayishimiye et al. (2023) [30] on the role of digital health tools in the COVID-19 response showed that these tools were frequently employed for diverse functions, with better adoption in high-income countries. These included facilitating virtual healthcare, offering clinical assistance, overseeing care quality, tracing and monitoring coronavirus transmission, and managing the inventory of medicines and vaccines [30]. However, disparities in internet access limited their adoption in LMICs and PHC settings located in rural and remote areas within high-income countries [63,75]. The adoption and success of eHealth in achieving UHC are also contingent on the presence and comprehensiveness of national eHealth strategies and policies with an overarching aim of achieving UHC via digitally enabled PHC service delivery. A recent global survey conducted by the WHO reported that more than half of the responding Member States have an eHealth strategy [7]. In Kerala, India, digital tools proliferated rapidly during the COVID-19 pandemic and helped meet diverse patient needs within PHC settings due to the foundation of their high-performing health system, existing eHealth strategy, and high levels of intersectoral collaboration, engagement with the private sector, and community volunteers [71]. Certain features of PHC practices, such as facilities with an affiliation to an academic institution and facilities that are located in an urban environment, can also increase the likelihood of eHealth adoption [54].