Digital Innovations Under Public Private Partnerships Contracts for Primary Care: Grounded Insights From an LMIC Setting

This paper uniquely explores the use of digital innovations within the ambit of domestically driven Public Private Partnership (PPP) initiatives in an Low-middle-income (LMIC) setting to improve primary healthcare delivery. The examination of PPPs continues to be centered on service volumes and economic efficiencies but attention to digital innovations has not been integrated into the examination of PPPs. We focus on digital innovations facilitated under four large-scale contracts awarded to non-government organizations (NGOs) for managing government primary health centers in Sindh, Pakistan. Data collection and analysis were guided by the objective to: i) understand the nature of digital innovations and the underlying purpose for achieving contractual goals; 2) determine the extent of rollout and stage of digital maturity; 3) explore implementation experience and identify synergies and barriers for improvements. Qualitative exploratory research methods of key informant interviews and field observations were applied. An analytical framework was developed to map digital innovations to World Health Organization's (WHO's) six building blocks; categorize digital innovations by the level of maturity and good practice parameters of functionality, user acceptability, data interoperability, standardization. Motivations, efforts and process were noted under each data category. We found that digital innovations proliferated under public sector primary care management contracts, driven by the impetus to meet contractual goals and minimize risks of non-performance. Innovations were aimed at countering staff absenteeism challenges, medicine stocks out and pilferages, and unreliable outpatient data. Flexible funding and decision space provided by the government to contracted NGOs were instrumental factors in rolling out of digital innovations. Key challenges included staff acceptance, technological issues of unreliable connectivity, frequent power outages, lack of mobile hardware, and data safety. While digital innovations addressed key operational bottlenecks faced by contracted NGOs, their broader strategic potential hinges on systemic enablers of addressing ethical risks, building standardization, stronger digital governance and developing digital capability. This would require a more proactive role from the government to reduce fragmentation while keeping the door open for innovations. In conclusion, future research and national strategies on PPP for healthcare delivery in LMIC settings must build centerfold attention to deployment of digital innovations as a critical parameter for PPPs design, implementation and evaluation. This will involve creating incentives for digital innovation while creating accountability for ethical data practices, interoperability and harmonization avoiding. New paradigm shifts are required that enable value creation between the public and private sectors and a shift from binary purchaser-provider relationship to pluralistic multistakeholder ecosystem that includes digital health stakeholders as well as societal representatives for patient centric innovations.