Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle-income countries

POLICY BRIEF Vol. 8, No. 1 2021 POLICY BRIEF Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle-income countries The Asia Paci�ic Observatory on Health Systems and Policies is a collaborative partnership which supports and promotes evidence-informed health policy making in the Asia Paci�ic Region. Based in WHO’s Regional Of�ice for South-East Asia, it brings together governments, international agencies, foundations, civil society and the research community with the aim of linking systematic and scienti�ic analysis of health systems in the Asia Paci�ic Region with the decision-makers who shape policy and practice. 978 92 9022 903 2

POLICY BRIEF Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle-income countries Shangzhi Xiong1 Lia M. Palileo-Villanueva2 Hao Li3 Abha Shrestha4 Peter O. Otieno5 Hongsheng Lu1 Lijing L. Yan1 1. Global Health Research Center, Duke Kunshan University, Kunshan, China 2. University of the Philippines, Manila 3. Wuhan University, China 4. Kathmandu University, Nepal 5. African Population and Health Research Center, Nairobi, Kenya World Health Organization Regional Office for South-East Asia Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle- income countries Comparative Country Studies. Vol-4, Number 1 ISBN 978-92-9022-903-2 © World Health Organization 2021 (on behalf of the Asia Pacific Observatory on Health Systems and Policies) Some rights reserved. 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Printed in India. iii Contents Acknowledgements v Abbreviations and acronyms vi Policy brief 1 Why do we focus on the use of e-health technology for urban primary care for noncommunicable diseases in low- and middle-income countries? 1 What do we know so far? 2 Policy suggestions for countries to consider 4 Working paper 8 Background and aims 8 Research design overview 9 Ethical considerations 10 Part 1: Scoping review 11 1. The use of e-health technologies for noncommunicable disease service delivery at urban primary health care settings in low- and middle-income countries 11 1.1 Methods 12 1.2 Results 14 Part 2: Qualitative research 24 2. The use of e-health technologies for noncommunicable disease service delivery in urban primary health-care settings in China, Nepal, Philippines and Kenya 24 2.1 Methods 24 2.2 Results 28 Discussion 48 References 52 iv Appendices 56 Appendix 1: Search syntax for the scoping review in three literature sources 56 Appendix 2: Listing of included papers from the scoping review by study types 58 Appendix 3: Semi-structured interview guide for the qualitative research 67 Appendix 4: Profile of participants of the qualitative research 70 Appendix 5: Profile of selected primary healthcare facilities for the qualitative research 78 Asia Pacific Observatory on Health Systems and Policies (APO) publications to date 82 vAcknowledgements We thank Ruoyu Yin (China), Anran Tan (China), Jhoanna Rose H. Velasquez (Philippines), Shrinkhala Shrestha (Nepal) and Gershim Asiki (Kenya) for their contributions to the working paper. Their names are listed at the end of the working paper as co-authors. Our sincere acknowledgements to the reviewers of the scoping review (Part 1 of the working paper): Alberto Najarro, Alexander Leandro dela Fuente, Don Jervis Sayman, Ege Duman, Namratha Atluri, Rinchen Doma, Sweta Kafle, Ying Wang and Zhao Ni (alphabetically ordered by first name), and our research assistants/ coordinators for the qualitative research (Part 2 of the working paper): Shuyang Wang, Yunan Mei, Namuna Shrestha, Rajani Shakya, Saurya Dhungel, Nikita Shakya, Roshan Kasti, Anusha Humagain, Jonina Martin, Ma. Rosario E. Bayan and Joy Bagas. We appreciate the support of and guidance from Professor Shenglan Tang (Duke University), Professor Abu Abdullah (Duke Kunshan University), Professor Soong Nang Jang (Chung Ang University), Professor Rohan Jayasuriya (University of New South Wales) and Ms Enying Gong (University of Melbourne) for their review of and valuable comments on this policy brief. We would like to especially acknowledge the contributions from many institutions and individuals who made this project a success. Our main collaborating institutions are Duke Kunshan University and Wuhan University (China); Dhulikhel Hospital, Kathmandu University Hospital (Nepal); the University of Philippines, Manila; and African Population and Health Research Center (Kenya). Other institutions also provided valuable support, including, but not limited to, the various governmental agencies and primary care facilities in three countries, Duke University (USA) and Universidad Peruana Cayetano Heredia (Peru). The project was led by Professor Lijing L. Yan with extensive central coordination by Mr Shangzhi Xiong and local leadership support from Professor Quan Wang (China), Professor Biraj Karmacharya (Nepal), Dr Catherine Kyobutungi and Ms Carol Wainana (Kenya). We would like to thank every person who participated in our interviews, without which this study would not have been possible. We acknowledge the funding support from the Asia Pacific Observatory on Health System and Policies, and additional financial support from Duke Kunshan University. vi Abbreviations and acronyms APO Asia Pacific Observatory on Health Systems and PoliciesCHW Community health workerICT information and communication technologyIRR interrater reliability MICs middle-income countries NCD noncommunicable disease PHC primary health care PRISMA Preferred Reporting Items for Systematic reviews and Meta-Analyses (guidelines)RCT randomized controlled trialUHC universal health coverageWHO World Health Organization 1Policy brief Why do we focus on the use of e-health technology for urban primary care for noncommunicable diseases in low- and middle-income countries? “e-Health” – defined by the World Health Organization (WHO) as “the use of information and communication technologies (ICT) for health” – has proliferated in recent years. This proliferation spans many areas of health and health care; however, the use of e-health tools for the prevention and control of noncommunicable disease (NCDs) in middle-income countries (MICs) is limited. Unlike many infectious diseases that are episodic in nature, NCDs often require long-term – even lifelong – health care that is prevention-oriented, proactive and patient-centred. These features naturally point to both the importance of primary health care (PHC) and the potential use of e-health technology for NCD control. As Internet and mobile phones sweep over nearly every corner of the globe, ICT tools have become an integral part of people’s lives and have the potential to transform the way we approach health promotion and health care. Whether such potential for e-health can be realized is still unclear. Many people hold the view that e-health might bring particular benefits for MICs as they struggle with more limited resources and larger disease burdens than what high-income countries face. This policy brief is a synthesis of the insights gained from systematic reviews of the published scientific as well as grey literature and in-depth interviews in four MICs – China, Nepal, Philippines and Kenya. The selection of these four countries was based on prior engagement and collaboration with the research teams in these countries, which, as MICs, have to deal with an increasing burden of NCDs but have a different demographic structure, socioeconomic status 2and e-health development landscape. The focus is on the use of e-health at the PHC level for NCD management in urban settings only due to the limited scope of the study and the often-large disparities between urban and rural areas in these countries. What do we know so far? The use of e-health is generally well accepted by multiple stakeholders The WHO definition of e-health was generally well understood and agreed upon by most of the interviewed policy-makers, experts, PHC providers and patients. Most stakeholders were aware of the existence of e-health and had a positive attitude towards it. The most mentioned purposes of using e-health was to improve efficiency, quality of care, patient experience and inform policy planning. A wide range of e-health services are already in use in urban primary care settings Many PHC facilities use a range of e-health services. On the provider side, these include electronic health records, examination reports, prescription systems and, less commonly, telemonitoring devices and electronic clinical decision-support systems. On the patient side, electronic appointments, queuing systems and mobile phone messaging services are the most widely mentioned services. In general, the range and importance of e-health services in use correlate with the economic development of the country, with China having relatively more applications than the other three countries. Within a country, in more developed regions, providers and facilities tend to use more e-health applications in PHC than in less developed areas. Private PHC facilities, specifically in the Philippines, tend to have a higher utilization and wider range of e-health technologies than public facilities. Perceived benefits of e-health outweigh perceived harms Policy-makers, experts, providers and patients all mentioned many perceived benefits of the use of e-health in PHC facilities. The most frequently described benefits for providers included a reduction in workload, higher efficiency and capacity in delivering services, and convenience in data storage and communications. On the patients’ 3side, commonly perceived benefits included better user experience and satisfaction, better continuity of care and better quality of care. Some interviewees also reported reduced health costs, improved health outcomes and better health-care coverage as important benefits of using e-health. Certain risks or harms were also perceived by our interviewees, especially PHC providers, which included increased workload for frontline workers mostly through repeated data entry and reporting, time needed for training, potential concerns regarding self-management by patients, and overreliance on ICT that, in case of technical failure, could cause severe disruption and have major consequences. In summary, the perceived harms were few and were outweighed by the perceived benefits. Facilitators for, and barriers to, e-health implementation coexist in urban primary care for NCDs A literature review and stakeholder interviews identified a range of issues regarding facilitators for and barriers to implementation of e-health in urban PHC settings for NCDs. Factors that would facilitate implementation include the following:• high-level factors such as strong government and leadership support, adequate funding and technological availability (e.g. cellphones and computers); and infrastructural stability (e.g. electricity and the Internet);• design-related factors for implementation and uptake, including user-centredness, localized and personalized (when feasible) design, interoperability and compatibility across different systems and facilities, and integration with routine provider responsibilities and existing information systems such as insurance scheme systems;• cultural and experiential factors, although more difficult to identify, included user acceptance and motivation, favourable experiences with e-health, and users' age and exposure to other ICT tools. Barriers identified included the absence of facilitating factors as well as concerns over legal issues, data security, conflicts of interest, language barriers, low user technical literacy and lack of adequate training for users. Many policy recommendations arose from the two components of the study – the scoping review and qualitative research through in-depth interviews with key stakeholders. The fact that they are 4often complementary and support each other is reassuring, as such triangulation of evidence also alludes to their consistency and importance. These firm recommendations should be cautiously used due to the small size of our study and lack of contextualization. Policy suggestions for countries to consider National and subnational levels• Strong policy and financial support. To promote sustainable development of e-health technology, it is essential to have long- lasting, consistent and strong policies specific to e-health, and regulations that also allow flexibility and innovation. Of note, regulations that address confidentiality, privacy and data security issues may vary from country to country but are not less important in MICs than in high-income countries. Equally fundamental is the provision of financial support. Investment from the private sector is a welcome addition, but public funding should be the cornerstone for supporting e-health at the PHC level.• Standardization of devices and systems. A major barrier to the effectiveness of e-health technology is the lack of standardization and compatibility across different hardware and software systems, and across different branches of health sectors and facilities. Enforcing the same set of devices or systems is not feasible or necessary, but interoperability and compatibility need to be emphasized at the national or regional level. Such emphasis will greatly reduce the difficulties in integration across systems and platforms and increase the efficiency of service delivery. This can potentially improve the quality and continuity of care through enhanced referral mechanisms.• Cross-sectoral collaboration. Successful development and adoption of e-health technology at the PHC level require inputs and collaboration much beyond PHC facilities and personnel. In an ideal case scenario, cross-sectoral collaboration should be in place, where government sectors encourage the development and standardization of e-health technologies through policies and regulations; different tiers of the health-care system are integrated in using e-health in a way that enables smooth communication, patient referrals and data management; local governments take charge of localizing and implementing e-health initiatives; the information and communication industry collaborates with 5academia in developing and improving innovative e-health strategies; and social media educates the general population and raises their awareness and acceptance of e-health technologies. Local and facility levels• Contextualized assessment. At the local (e.g. a city) and facility levels, contextual assessment is crucial for the successful development and implementation of e-health programmes, but this is often overlooked in policy-making and programme development. The necessity of contextual assessment comes from the vastly different local situations that the technology and programme will be implemented in. Such assessments should include a local health and health-care needs assessment (e.g. prevalence, treatment and control of hypertension and diabetes), local capacity assessment (e.g. ICT infrastructure, technical literacy and readiness) and local cultural assessment (e.g. languages and customs). Field-based pilot-testing is also recommended before large-scale roll-out.• Integration of different e-health platforms. Having to work with several different systems is a common complaint at the PHC level for e-health, including for NCD care. We highly recommend having integrated or at least compatible systems to reduce the need for end-users to learn multiple systems and for repeated data entries. Integrated systems will also generate new opportunities to enhance the benefits that accrue from adopting e-health technology. We will need both technological advancements in favour of compatibility and integration, and management and governance strategies to ensure market efficiency and competition.• Technological availability and stability. Assurance of a steady power supply and Internet connectivity can be difficult in certain MICs and thus needs special attention from the local government and designers when implementing e-health programmes. Similarly, back-up servers and systems are needed to avoid accidental data loss, and technical know-how and support for secure transmission and storage of electronic health-related data. Primary care provider level• Training and education. The role of PHC providers is critical in ensuring successful use of e-health technology to achieve its desired benefits. PHC providers include not only general practitioners, 6family doctors, and facility managers and administrators, but also physician assistants, nurses, pharmacists and community health- care workers. Appropriate training and retraining to build and keep up their technical literacy may appear obvious but are, in practice, often lacking or inadequate. Examples of effective training programmes are cascade training (“train the trainer to train” model), case-based participant-centred, and on-the-job training programmes.• Motivation and incentives. PHC providers need both internal and external motivation to adopt newer technology. Often, their need to become and stay motivated are overlooked, leading to failure or reduced effects from the implementation of e-health programmes. In our study, this point was repeatedly emphasized by multiple sources and different interviewees, indicating its importance. Financial incentives are common and usually effective, but other forms such as awards and non-monetary benefits should also be part of a holistic evaluation and reward system. The design of effective motivation and incentives for PHC providers should incorporate insights gained from behavioural and psychological sciences. One exemplar non-financial incentive to enhance PHC providers’ use of e-health is to combine performance evaluation into the PHC providers’ e-health practices .• Periodic monitoring and evaluation. There is a need to put in place easy-to-implement and cost-effective monitoring and evaluation measures. These measures should be geared toward evaluating not only end-user experiences and performance but also the effectiveness of e-health programmes in achieving their designed purposes. Ideally, the outcomes of the evaluation should be tied with the vested interests of the key players in the programme, such as designers, technical companies, providers and PHC facilities, and inform dynamic improvements in and updates of the e-health programmes. Individual and patient level• User-centred design. This principle has been strongly promoted by many e-health practitioners. Our study also consistently echoed this point. It is listed under the individual and patient level as they are often the users of various e-health programmes but it equally applies to other users such as providers and administrators. To achieve this goal, end-users need to be involved early (in the needs 7assessment, design and pilot stages) and their feedback actively sought and heeded throughout.• Personalization and customization. Patient-targeted e-health programmes in MICs are still relatively uncommon, and they are often one-way and not individualized. It is clear from our interviews that in MICs, the need for personalization and customization is strong for designing and implementing e-health. Its achievement – albeit requiring extra programming or provisions – can often be realized in a low-cost way through ICT. Such personalization and customization may consider users’ demographic information (e.g. age, gender and literacy), health conditions and personal preferences (e.g. dose/frequency, timing and design of users’ interface, such as fonts, colours and layout of the visualizations of smartphone apps).• Behavioural modification. Use of e-health technology at the PHC level can bring many benefits to patients and community residents such as information, convenience and potential improvements in the quality of PHC. Ultimately, the goal of any new technology is to improve health outcomes. One fundamental way to achieve this is through behavioural modification, which can be challenging. Evidence has shown that e-health technology, when used in combination with provider–patient interactions and active self-management activities, can be effective in promoting and maintaining healthy behaviours such as medication adherence, physical activity and attendance at health seminars. In fact, effects on such behavioural outcomes are more substantial than that of direct clinical outcomes according to existing studies. Therefore, it is advisable that adoption of e-health in PHC settings incorporates evidence-based components of behavioural modification and evaluates the changes in people’s behaviours in addition to clinical indicators. 8Working paper Background and aims The importance of primary health care (PHC) in providing accessible, affordable and high-quality universal health coverage (UHC), especially for noncommunicable diseases (NCDs), has long been recognized by the World Health Organization (WHO), national health reform champions, and researchers [12]. In our previous study funded by the Asia Pacific Observatory on Health Systems and Policies (APO), we confirmed the critical role of PHC in the prevention and control of cardiometabolic diseases, which is one of the most prominent NCD groups [3]. However, we also found several major barriers that prohibited PHC from providing accessible and high-quality care, including suboptimal qualifications of PHC personnel, lack of professional training, work overload of PHC providers, limited access to PHC in low-resource settings, and unavailability of medicines and equipment [3]. The previous study highlighted the need for innovative approaches to strengthening PHC to achieve UHC. E-health systems have the potential to strengthen PHC in ways that are both economically viable and sustainable. WHO defines e-health as the use of information and communication technologies (ICT) for health, which encompasses improving the flow of information, through electronic means, to support the delivery of health services and the management of health systems [4]. It is an emerging field in the intersection of medical informatics, clinical practices, public health and business, and it is the cost-effective and secure use of ICT in support of health and health- related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research [5]. Various studies have been conducted to explore the effectiveness of e-health technologies in improving service delivery, and these have shown 9that e-health has the potential to improve the quality of care, extend the scope and reach of health-care services, reach difficult-to-reach populations, bridge geographical divides and achieve cost–effectiveness in service delivery [6–8]. However, most of the studies were conducted in high-income countries or among advanced health facilities such as tertiary hospitals, where e-health tools are better integrated into routine practices. Systematic evidence on the utilization of e-health in strengthening NCD service delivery at the PHC level in low- and middle-income countries (MICs) is far from adequate, despite the proliferation of new but often fragmented e-health initiatives. Further endeavours are needed to explore the perceptions, uptake and utilization of e-health technologies at the PHC level in MICs, and to better understand how e-health can be integrated within existing health-care systems. The overarching goal of this working paper is to investigate the steps needed to create a favourable environment for the implementation and utilization of e-health services to deliver NCD services at the PHC level. The study focused on urban PHC settings due to the often-large disparities between urban and rural areas in MICs and the limited scope of the research. We had four specific objectives: 1. To review and document the use of e-health technologies for NCD service delivery at the PHC level in urban settings in MICs; 2. To explore the understanding and perceptions of e-health technologies among policy-makers, health-care experts, urban PHC facilities and NCD patients in the selected MICs; 3. To identify facilitators of and barriers to the design, uptake, utilization and maintenance of e-health technologies at the PHC level in urban settings; 4. To explore, where there is active use of e-health technologies, how to better integrate the e-health technologies into the existing health-care system. Research design overview Our study had two components: (1) scoping review of existing publications, and (2) qualitative research through key informant interviews in real- world settings. Part 1: Scoping review. We conducted a scoping review of academic databases and official websites of health-related international organizations under the topic “The use of e-health technologies for noncommunicable disease service delivery at urban primary health care 10 in low- and-middle-income countries”, to mainly address objectives 1 and 3. Part 2: Qualitative research. We conducted qualitative research through in-depth interviews with policy-makers and experts in health-related fields and key informants from urban PHC facilities in four selected MICs: China, Nepal, Philippines and Kenya, to mainly address objectives 2, 3 and 4. The key informants in PHC facilities included facility administrators, health-care providers and patients who sought care from the facilities. Notably, because of the broad connotations of NCDs in the literature and in practice, we used two tracer conditions, hypertension and diabetes, which are two of the most prominent NCD conditions in general, to follow the thread of service delivery at the PHC level. This helped us narrow down the scope when selecting the literature and recruiting study participants, while still allowing us to investigate the general situation of NCDs. Based on the prior engagement and collaboration network of the research team, we selected three Asian countries – China, Nepal, Philippines, and one African country – Kenya, to conduct our study. These four countries are similar, as they are MICs confronting the increasing burden of NCDs and are planning to strengthen their PHC systems. They are also distinctive from each other, however, in their demographic structure, socioeconomic status and their situation of e-health development. We envision that the comparison of research findings among the four chosen countries may demonstrate common challenges and opportunities in MICs as well as features unique to each country. Project implementation was standardized across all four countries to ensure compatibility of results while also allowing appropriate adjustments to be made based on the local context in each country. Ethical considerations The study was approved by the Duke Kunshan University Institutional Review Board (IRB). Local IRB approvals were obtained in each country with support from local collaborators. Written informed consent forms were obtained from the participants before any data were collected. Confidentiality of the research data was ensured in all the selected countries. 11 Part 1: Scoping review 1. The use of e-health technologies for noncommunicable disease service delivery at urban primary health care settings in low- and middle-income countries There are many systematic reviews in the existing literature that explore the role of e-health technologies in different settings. These reviews have different focuses, including, for example, e-health’s economic impact [9], evidence-based e-health evaluation [10], and e-health’s effectiveness on specific health indicators [11]. These reviews provided abundant information about the promising application of e-health for various health services. However, most of these reviews included studies that were predominantly conducted in high-income countries and in higher-end settings, such as tertiary hospitals. There is currently a lack of knowledge of the situation of e-health usage at PHC settings in MICs, particularly for NCD-related service delivery. To bridge this gap, we conducted a scoping review to identify the use of e-health technologies for NCD service delivery at PHC settings in MICs. We further limited our review to urban settings due to the often-large disparities between urban and rural areas in MICs and the limited scope of the main research. The scoping review protocol with a detailed search strategy was developed through the collective efforts of researchers in the collaborating countries, and the detailed search syntax is attached as Appendix 1. Specific research questions of the scoping review included: What are the uses of e-health in NCD service delivery at urban PHC settings in MICs and what is the effectiveness of using e-health? What are the barriers to 12 and facilitators for the use of e-health in NCD service delivery in the PHC settings? And what are the possible strategies to enhance the integration of e-health technologies within the existing health systems? 1.1 Methods Databases We included three sources of literature: English academic databases (i.e. PubMed, Embase and Web of Science), Chinese academic databases (i.e. CNKI, WanFan and the VIP), and the official websites of international health-related organizations (WHO, the World Bank, International Telecommunication Union, Health Systems Evidence Service and Asian Development Bank). Search strategy We used a standardized search strategy across all the three literature sources. We had three main groups of keywords in our search syntax: words related to e-health (e.g. electronic health, mobile health, short message service, electronic health record), words related to primary health care (e.g. primary care, essential health care), and words related to NCDs (e.g. hypertension, diabetes, cardiovascular diseases). The equivalent of the keywords in Chinese were used in the literature search on Chinese databases. A more detailed search syntax is attached as Appendix 1. Inclusion criteria• Papers that focused on the use of e-health technologies for service delivery at the PHC level• Scope of “service delivery” included curative, preventive and rehabilitative service delivery.• “Disease types” included papers that covered NCDs or NCD risk factors but were not necessarily exclusively about NCDs or NCD risk factors.• “Study settings” included papers that focused on urban settings in Low and MICs.• “Publication years” included papers that were published after 2000.• For papers from academic databases, we included both reviews and original experimental studies. 13 • For papers from the official websites of international health-related organizations, we included original research papers, review papers and bulletins. Exclusion criteria• Protocol papers after attempting to find the related final publications• Papers whose full texts were not accessible after contacting the corresponding author and seeking support from library literature support staff• Papers whose full texts were not available (e.g. conference abstracts)• Papers that were not written in English or Chinese. Paper selection and review process We took a four-step process for the selection of relevant papers, guided by the PRISMA extension for scoping reviews (PRISMA-ScR) [12]. First, we conducted a pilot search on the English academic databases and identified several high-quality systematic reviews on related topics. We studied these review papers and polished our search syntax based on their search terms. Second, we commenced a literature search on the three mentioned literature sources and conducted the first round of screening by the search results’ titles. We conducted the second round of screening by abstract for papers that were included from the first round of screening. Finally, based on the eligibility criteria, we conducted the final round of screening by full texts for papers that were retained from the second round of screening. Data extraction was then performed on papers that were included in the final shortlist. We had three groups of reviewers working on the three sources of literature. We ensured that each search result was independently screened by two reviewers. Discrepancies between the two reviewers were discussed until agreement was reached or a third reviewer made an assessment. We used the EndNote software for literature management in this process. Data extraction process We adopted an iterative process for data extraction by multiple independent reviewers to ensure the quality of data extraction and consistency of formatting. Data from the Chinese papers were not translated into English until the contents were repeatedly modified and finalized to ensure information fidelity. 14 Information that we extracted from each paper included basic information (i.e. authors’ names and publication year), study type and design, e-health applications covered in the study and the main findings, including the effectiveness, barriers/challenges to the use e-health, facilitators for the use e-health and implications/recommendations. 1.2 Results We identified a total of 6099 records in the initial search, including 4277 records from the English databases, 1762 from the Chinese databases, and 60 from the websites of international health organizations after deleting duplicates within each data source. After three rounds of screening in the academic databases and one round of screening in the international organization websites, we included 21 English papers, 19 Chinese papers and 58 organization documents for data extraction. Fig. 1.1 shows the flowchart of the paper selection from the English and Chinese databases, and international organization websites separately. After pulling together all papers from the three sources and deleting duplicates between papers from the English academic databases and the international health organization websites (n=10), we further regrouped the final included papers (n=88) by their different study designs, which included 27 review papers (listed in Appendix 2.1), 33 experimental study papers (Appendix 2.2), and 28 documents published by organizations (Appendix 2.3). 15 Fi g. 1 .1 : F lo wc ha rt o f p ap er se le ct io n fo r t he sc op in g re vi ew Re co rd s i de nt ifie d (n = 61 ) • W HO : 1 3 • He alt h sy st em s e vid en ce se rv ice : 2 4 • As ian D ev elo pm en t B an k: 8 • W or ld B an k: 6 • In te rn at ion al Te lec om m un ica tio n Un ion : 1 0 Du pl ica te s r em ov ed (n = 1) Fu ll- tex t a rti cle s e xc lu de d (n = 2) Re co rd s s cr ee ne d (n = 60 ) St ud ies in clu de d in an aly sis (n = 5 8)In te rn at ion al or ga ni za tio n we bs ite s Re co rd s i de nt ifie d (n =2 14 1) • CN KI : 9 03 • W an fan g: 61 1 • VI P: 62 7 Du pl ica te s r em ov ed (n = 37 9) Ex clu de d by ti tle (n = 15 20 ) Ex clu de d by ab st ra ct (n =1 38 ) Fu ll- tex t a rti cle s e xc lu de d (n =8 5) Re co rd s s cr ee ne d by ti tle (n = 17 62 ) Re co rd s s cr ee ne d by ab st ra ct (n = 24 2) Fu ll- tex t a rti cle s a ss es se d fo r e lig ibi lit y ( n = 1 04 ) St ud ies in clu de d in an aly sis (n = 19 ) Ch in es e d at ab as es Re co rd s i de nt ifie d (n = 68 86 ) • Pu bM ed : 1 78 3 • Em ba se : 2 92 6 • W eb of sc ien ce : 2 17 7 Du pl ica te s r em ov ed (n = 26 09 ) Ex clu de d by ti tle (n = 31 94 ) Ex clu de d by ab st ra ct (n = 87 7) Fu ll- tex t a rti cle s e xc lu de d (n = 18 5) Re co rd s s cr ee ne d by ti tle (n = 42 77 ) Re co rd s s cr ee ne d by ab st ra ct (n = 10 83 ) Fu ll- tex t a rti cle s a ss es se d fo r e lig ibi lit y ( n = 2 06 ) St ud ies in clu de d in an aly sis (n = 21 ) En gl ish d at ab as es 16 Study characteristics The 27 review papers could be primarily separated into three types: systematic reviews (n=17), scoping reviews (n= 6), and umbrella reviews (n=4). The reviews covered primarily randomized controlled trials (RCTs), clustered RCTs, quasi-experimental studies, qualitative research papers, observational studies and government reports. One systematic review focused on reviewing mobile phone apps rather than reviewing academic publications. Most of the 33 experimental studies were RCTs (n=17); some were uncontrolled or self-controlled trials (n=8) and some were quasi- randomized trials (n=8). Most of the studies had one of the two types of participants in the studies – NCD patients and PHC providers, while one involved both types of participants. There was a wide range of sample sizes from 10 to 30 014 due to the different natures of the studies. The follow-up time varied from 2 months to 18 months, but most of them were no longer than 12 months. The 28 organizational documents included organizational reports (n=11), handbooks (n=4), case study (n=1), policy brief (n=1), framework user manual (n=1), working paper (n=1), conference proceedings (n=1), reviews (n=3), country profile (n=1), compendium (n=1), framework proposal (n=1), discussion paper (n=1) and toolkit (n=1). Types of e-health applications We identified various types of applied technologies that fit WHO’s definition of e-health – “the use of information and communication technologies for health”. The most frequently studied e-health technologies in the research papers could be generally divided into two groups based on who the technologies mainly targeted. First, the e-health technologies that mainly targeted NCD patients included smartphone-based applications (apps), short message services (SMS), home-monitoring devices and multimedia message service (MMS, e.g. voice messages/videos). Second, the e-health technologies that mainly targeted PHC providers included electronic health record (EHR) systems, clinical decision support systems and communication systems. Most of the experimental studies incorporated multiple kinds of e-health technologies in their intervention designs. 17 Study outcomes and effectiveness of e-health Given the wide range of the selected studies, we found three major types of primary outcomes: clinical outcomes, behavioural outcomes and implementation outcomes. Examples of clinical outcomes included the control rate for systolic and/or diastolic blood pressure, blood glucose, blood lipids, body mass index (BMI) and waist circumference. Examples of behavioural outcomes included medication adherence, diet patterns, physical activities, therapeutic inertia, attendance rate at health education sessions, and other disease self-management actions. Major implementation outcomes included accessibility, feasibility, fidelity and maintenance of the interventions, acceptability and drop-out rates, and user experience and satisfaction. The effectiveness of e-health technologies varied across the three types of outcomes (Table 1.1). For the clinical outcomes, the results were highly mixed, and both positive and neutral results were common. Relatively speaking, there were more positive results in the behavioural outcomes, where studies observed significantly better medication adherence or other health management actions attributed to the e-health interventions. Importantly, most studies that investigated implementation outcomes found promising results in the feasibility, acceptability, user experience and satisfaction indicators when using e-health applications, while a few of them reported negative implementation outcomes, which were mainly attributed to a lack of personnel training. One major positive effect in implementation that was the most frequently reported was the substantially improved coverage and reachability of health services as a result of e-health technologies. 18 Table 1.1: Summary of the effectiveness of e-health in the three types of outcomes for noncommunicable disease-related service delivery at the primary health-care level Outcome types Positive Negative/Neutral Clinical outcomes • Improved blood pressure control (e.g. systolic, diastolic and mean blood pressure)• Improved blood glucose control in diabetic patients (e.g. HbA1C)• Improved blood lipid management (e.g. LDL cholesterol level)• Reduced weight/BMI• Reduced cardiovascular risk composite scores• Reduced incidence of cardiovascular and cerebrovascular events• Reduced all-cause mortality• Reduced heart failure-related readmissions• Reduced numbers of hospitalizations and emergency visits • Neutral results for blood pressure control• Non-significant effects on blood glucose control• No effect on the incidence of cardiovascular diseases• Mixed effects on all- cause mortality• Mixed effects on cardiovascular mortality• Mixed effects for quality of life Behavioural outcomes • Improved adherence to medications• Improved adherence to disease monitoring• Improved adherence to clinical appointments• Reduced therapeutic inertia• Improved adherence to physical activities• Improved adherence to diet plan (e.g. reduced salt/oil intake intake) • Mixed effects on medication adherence• Non-significant effects on adherence to clinic visits and emergency hotline calls• Mixed effects for adherence to blood glucose measurement• Mixed effects for diet quality Implementation outcomes • Increased NCD early detection rates• Improved timeliness of care• Increased accessibility to care• Improved user experience• Facilitated data collection and monitoring• Improved capacity among PHC providers • Emergent challenges in personnel training 19 Facilitators for and barriers to using e-health technologies We identified many factors that facilitate or act as barriers to the use of e-health technologies for NCD service delivery at PHC settings, and they can be summarized in three domains (Table 1.2): (1) factors associated with the political and technological environment; (2) factors associated with the design of e-health technologies; (3) factors associated with users of e-health, including at PHC facilities and NCD patients. Table 1.2: Summary of facilitators for and barriers to the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings Environment Facilitators Barriers Political and technological environment • Policies and regulations for e-health being in place• Technology development• Cellphone penetration in the general population • Lack of proper policy regulation and standardization• Technological limitations (e.g. unavailability and instability)• Inaccessibility to marginalized regions and populations• Unaddressed data security issues• Unaddressed e-health ownership issues e-health design • Users’ active involvement in design• Appropriate designs that fit into routine responsibilities and reduce workload• Incorporating mutual communications with patients• Tailored design and personalized content for patients • Lack of user involvement in design• Arbitrary design that causes redundant work• One-way information flow and lack of human communication• One-for-all unified content and design e-health users • Adequate personnel training for PHC providers• Adequate guidance for patients• Having incentives for using e-health• Active interactions between providers and patients • Lack of personnel training for PHC providers• Lack of guidance for patients• Lack of incentives and motivation for e-health• E-health overshadowing human interactions between providers and patients• Technological illiteracy among lower socioeconomic classes 20 As is presented in Table 1.2, the advancing development and prevalent use of ICT is an important facilitator for the successful use of e-health technologies. However, the unavailability of e-health services in marginalized regions and technical issues such as poor Internet connectivity, together with people’s technical illiteracy, remain important barriers. Second, policy regulations that encourage and standardize the use of e-health technologies are facilitators that help to substantiate the use of e-health technologies, while the absence of proper policy regulations is a barrier. Third, regarding e-health design, arbitrary designs of e-health without users’ involvement, designs that overemphasize one-way information flow instead of patient–provider interactivity, and one-for- all unified content and design without any personalization are commonly considered barriers to successful e-health applications. Moreover, the involvement of mobilizers from local communities was found to facilitate the use of e-health. Implications and recommendations Almost all studies tended to support the use of e-health for NCD service delivery in PHC settings or at least warranted further investigation to optimize its use. Major implications and recommendations for the use of e-health at PHC settings from the current studies can be summarized in five aspects: regulations, design, uptake, maintenance and evaluations, and research (Table 1.3). 21 Table 1.3: Recommendations from the scoping review for improving the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings Aspects Recommendations Regulations • To have governing regulations in place• To encourage e-health innovations and technology advancement• To facilitate standardization of the use of e-health• To address safety concerns and ownership issues• To reach underserved populations and regions Design • To have a user-centred design by engaging stakeholders in the development phase• To incorporate established health behavioural theories and models• To have customization and personalization of contents and formats• To ensure the “human” component in e-health and facilitate communications• To integrate e-health with primary health-care providers’ routine responsibilities Uptake • To provide high-quality personnel training for primary health-care providers• To provide incentives and motivation for primary health- care providers• To provide adequate training and continuing guidance for NCD patients Maintenance and evaluation • To engage a local mobilizer from the community to ensure long-term effects• To ensure interaction and communication between different stakeholders to identify areas for improvement• To perform process evaluations for implementation outcomes• To perform cost–effectiveness analysis Research • To conduct further research with rigorous designs, longer follow ups and larger sample sizes• To explore and represent diverse populations and settings, especially underserved populations and those in resource- limited settings 22 Many studies reported the benefits of adopting user-centred designs by actively involving users in the development phase. Personalized information and content tailored to users’ dynamic status were preferred over unified information and content. Such customization may consider the users’ demographic information (e.g. age, gender and literacy), health conditions, and personal preferences (e.g. dose/frequency, timing and colour and layout visualizations of smartphone apps). In addition, some studies recommended incorporating established theories and models to guide the e-health design; for example, use of the innovation diffusion model, health belief model or stage-of-change model. Fourth, some studies recommended periodic process evaluations to determine the implementation status and cost–effectiveness, as well as examining the efficacy on health outcomes. Finally, many studies acknowledged the limitations of the existing literature due to limited sample sizes and short study durations, and they called for research with more rigorous designs and on a larger scale with longer follow-up periods. Based on the scoping review described in Part 1, and the four-country qualitative research to be described in Part 2, we created a taxonomy for e-health technologies used for NCD-related service delivery activities at the PHC level (see box). We referred to two main publications on e-health- related frameworks to develop this taxonomy [13 14]. Of note, all listed e-health applications in this taxonomy are associated with NCD care services, but they are not necessarily exclusively used for NCDs, with some of them also covering other health services (e.g. infectious diseases, maternal and child health, and injuries). We divided the e-health technologies by its two types of target users: PHC providers and NCD patients, and then further classified the different e-health technologies by their primary functions, informed by the scoping review and qualitative research. 23 Box: Taxonomy for e-health technologies for noncommunicable disease-related service delivery at the primary health-care level Primary functions For PHC providers For NCD patients To reduce workload or improve user experience • Electronic examination report• Electronic prescriptions• Digital-based data collection and reporting• Electronic financial transactions • Electronic appointment• Electronic queuing• Electronic financial transactions• Electronic health insurance services To facilitate communications • Short message services• Multimedia message services• Interactive voice response (for patient–provider communication) • Short message services• Multimedia message services• Interactive voice response• Online information platforms (for patient– provider and patient– patient communication) To promote continuity of care • Telemonitoring (e.g. sensors, wearable trackers)• Point-of-care systems• Digital-based patient referral systems • Telemonitoring (e.g. sensors, wearable trackers)• Point-of-care systems• Health education apps To improve facility management • Electronic inventory for medical supplies• Digital-based supply chain management• Digital-based human resource management NA To improve accountability and quality of care • Electronic decisions support (e.g. protocols, algorithms, checklists)• Electronic health record• Electronic disease screening/diagnosis• Online provider training and education NA 24 Part 2: Qualitative research 2. The use of e-health technologies for noncommunicable disease service delivery in urban primary health-care settings in China, Nepal, Philippines and Kenya We conducted qualitative research through in-depth interviews with diverse key-stakeholders in four selected MICs: China, Nepal, Philippines and Kenya. The specific objectives of this part were: (1) to understand key stakeholders’ awareness of, and attitudes towards e-health for NCD service delivery at the PHC level in the selected countries; and (2) to explore facilitators for, barriers to, and suggestions for the use of e-health in NCD service delivery at PHC settings. Specific research questions that this part tried to address included: how do the key stakeholders perceive the use of e-health technologies at PHC settings? What are the barriers and facilitators that key stakeholders perceive in using e-health for NCD service delivery at the PHC level? And, where e-health is actively used, how to better integrate e-health into the existing health systems? 2.1 Methods Participant eligibility criteria There were five types of participants in the qualitative research: (1) national and regional policy-makers; (2) experts in health-related fields; (3) PHC facility administrators; (4) PHC providers (i.e. doctors or nurses) who were authorized to manage hypertension/diabetes in the selected 25 PHC facilities; and (5) residents with hypertension and/or diabetes who attended the selected PHC facilities. The inclusion criteria for policy-makers were government officers who had worked as policy-makers in health departments for at least one year; who were willing to provide informed consent and share their insights about e-health technologies and PHC. We aimed to include one national policy-maker and two regional policy-makers from each country. The inclusion criteria for expert interviewees were academic or industrial opinion leaders who had worked in the relevant fields for at least five years and were willing to provide informed consent. We aimed to include a total of five experts in the fields of e-health, PHC and/or NCDs from each country. For PHC administrators, the inclusion criteria were the manager, the head or the person in charge of the selected PHC facilities; or the senior most health professional working in the selected PHC facilities if the manager, the head or the person in charge was not available. For PHC providers, the inclusion criteria were the doctors who directly worked at the PHC facility; or the nurses who directly worked at the PHC facility if the doctors were not available. For NCD patients, the inclusion criteria were people who had been diagnosed with hypertension and/or diabetes who sought routine care at the PHC facility for their conditions. We excluded participants who had worked at/sought care from the PHC facility for less than three months, those who had serious impairment for research completion (e.g. muteness, deafness) and those who could not provide informed consent. Study site selection Site selection was assisted by local collaborators in each of the four countries to ensure the representativeness and feasibility of these sites for project implementation. In China, Nepal and Kenya, we first identified two cities in each country, and then purposefully selected three PHC facilities that had distinctive features in each city, including the size of service coverage, level of infrastructure and the status of their e-health technology usage. In the Philippines, similar approaches were adopted except that we selected three public PHC facilitates and three private facilities in one highly urbanized city, as was proposed by the local collaborators. In each PHC facility of the four countries, we 26 included one administrator, one provider and one NCD patient for the interviews. Stakeholder interviews were conducted before the onset of the COVID-19 outbreak. Interview guide We designed the semi-structured interview guide based on the scoping review, as described earlier, and discussions among the research team and experts. There were six sections in the interview guide: (1) basic information about the interviewee; (2) basic information about the interviewed facility; (3) the interviewee’s understanding of the definition of e-health; (4) the interviewee’s opinions on the barriers to and facilitators for the uptake, utilization and maintenance of e-health at PHC level; (5) interviewee opinions about the integration of e-health technologies with the PHC system; (6) other suggestions and comments about e-health. The full version of the standardized semi-structured interview guides is attached in Appendix 3. The basic structure of the interview guide was standardized across the four countries while allowing and encouraging localization in each country based on their local contexts, especially considering the different situations for their use of e-health technologies. For example, in countries where e-health is still extremely limited at the PHC level (e.g. Nepal), questions were focused on the first four sections of the interview guide, while in countries where there has been active use of e-health (e.g. China), more attention was brought to section five. Interviewer training All interviews were conducted in local languages by trained interviewers from the study countries. The interviewers were first trained in general skills and ethics of conducting qualitative data collection, and were then familiarized with the standard interview guide. The interviewers were encouraged to modify the interview guide by forming their own questions based on their understanding and knowledge of the local situation and developing probes that arose following the actual responses during data collection. 27 Thematic coding process We conducted thematic coding of all interview transcripts in a manner that combined deductive and inductive coding strategies. Deductive coding was applied to identify the main topics covered in the interview guide (e.g. purposes and benefits of and facilitators for using e-health), and inductive coding was applied to elicit specific themes under each topic (e.g. workload reduction, improved efficiency, personnel training). We took the following steps to complete the coding process: Two independent coders from each country conducted pilot coding for 10% of the total interviews in the country. The two coders compared their codebooks and created one mutually agreed codebook with clearly defined themes. Using the mutually agreed codebook, the two coders revised their coding and calculated their interrater reliability (IRR). This step was repeated until the IRR reached the predefined target of 70%. The Duke Kunshan University team collected the pilot coding codebooks from all four countries and created a unified codebook by compiling and reorganizing all the generated themes and adding potential themes that were identified from the literature reviews and team discussions. The DKU team then shared the unified codebook with all collaborators, who commenced coding of all the transcriptions. All interviews were transcribed verbatim in the original language in which the thematic coding was conducted. The information was not translated into English until the coding process was iteratively modified and finalized to ensure the fidelity of information during language translation. Coding was undertaken using NVivio 12 software (QSR International). 28 2.2 Results Facility and participant profile We obtained the expected numbers of interviews with all kinds of stakeholders in all countries and exceeded some of the numbers. Table 2.1 shows the quantitative summary of interviews conducted in each country. Details about the interviewees’ profiles are shown in Appendix 4. Table 2.1: Summary of stakeholder interviews in China, Nepal, Philippines and Kenya Country Policy- makers Expertsa PHC facilities PHC administrators PHC providersb NCD patientsc China 3 5 6 6 6 7 Philippines 3 5 6 6 18 18 Nepal 4 5 6 6 6 6 Kenya 3 5 6 6 6 6 a Experts’ areas included PHC, NCDs, e-health and hospital management b Either doctors or nurses c People who were diagnosed with hypertension and/or diabetes The selected PHC facilities were diverse in capacity and population coverage. Their estimated number of daily outpatients ranged from 10 to 450. Half of the facilities had no inpatient services. The number of doctors per facility in China ranged from 11 to 35 (with one outlier being 74 doctors), and nurses from 7 to 35 (with one outlier being 168 nurses). For most PHC facilities in the other countries, there was only one doctor and less than two nurses. In some of the PHC facilities, there were a few other medical personnel, such as midwives, laboratory technicians, pharmacists and community health workers. Details of the PHC facility profiles are shown in Appendix 5. Overview of themes The identified themes from the interviews were primarily summarized into four major topics: (1) participants' understanding of the definition of e-health and their perceptions about e-health in general; (2) participants' perceptions about the benefits of and harms from using e-health for NCD service delivery at PHC settings; (3) participants' opinions on the barriers to and facilitators for using e-health for NCD 29 service delivery; and (4) participants' suggestions to better integrate e-health into NCD service delivery at PHC settings. The four thematic tables, Table 2.2 to Table 2.5, cover the four major topics, respectively. Understanding and perceptions about e-health technologies Table 2.2 shows the themes we identified about interviewee understanding and perceptions of e-health technologies in general. Most participants in all the four countries agreed with WHO’s definition of e-health, which is “the use of information and communication technologies for health”. Several modifications to the definition were proposed, including broadening the scope by including all innovative technologies or specifying e-health’s functions in the definition. Most participants in all the countries were aware of the use of e-health in the health systems of their countries and were supportive about the use of e-health for service delivery. Some participants, however, mostly in Nepal and Kenya, showed neutral attitudes toward using e-health. “There are additional benefits of e-health, but it cannot totally replace our conventional services……It is required but there may be limited or fixed areas in which e-health can be used. Everything is not possible through e-health.” — Policy-maker, Nepal One participant was even negative about using e-health for NCD service delivery. “E-health should not be brought into existence. If brought, there will be a lot of dependence on e-health. How can we follow up the patients, and understand how my patient is doing? It is only good to talk to him (in person). E-health will increase the gap between the doctor and the patient.” — PHC provider, Nepal Participants reported various purposes for using e-health for NCD service delivery: to improve PHC providers’ work efficiency and reduce workload, to increase convenience and safety for data storage, to improve the quality of care and patients’ health outcomes, to provide clinical guidance for PHC providers, to improve communications between patients and PHC providers, to improve the patient's experience and satisfaction when seeking care, and to inform policy planning and implementation through massive health information. In addition, several interviewees in China reported purposes regarding data analysis and health surveillance 30 through e-health, and some interviewees, mainly in Philippines and Kenya, mentioned that they used e-health only because of government requirements. Table 2.2: Understanding and perceptions of e-health technologies from key informant interviews in China, Nepal, Philippines and Kenya Themes Key information about each theme Countries Topic: e-health definition Agreement with WHO’s definition • Most participants agreed with WHO’s definition All Disagreement with WHO’s definition • To broaden the scope and include all innovative strategies for health• To specify e-health’s functions• To use easier terminology when explaining to local people• To add information about different types of users• To focus only on electronic health devices Kenya, Nepal, China Topic: Awareness about e-health Aware about e-health • Almost all participants were aware of e-health technologies All Unaware about details • Several mentioned that they did not know the details Nepal Unaware • A few patients were unaware of e-health technologies Philippines, China Topic: Attitudes toward e-health Positive • Most participants supported the use of e-health All Neutral • Some showed neutral attitudes toward e-health All Negative • A few showed negative attitudes toward e-health Nepal, Philippines 31 Themes Key information about each theme Countries Topic: Purposes for using e-health technologies at PHC facilities Work efficiency • To improve work efficiency by reducing repetitive work (asking for disease information) All Quality of care • To improve the quality of care and patients’ health outcomes All Workload reduction • To reduce workload by turning some paper-based work into electronic- based Philippines, China, Kenya Data storage • To increase convenience and safety of data storage Philippines, China, Kenya Clinical guidance • To provide PHC providers with convenient clinical guidance and decision support Philippines, Kenya Patient experience • To improve patients’ experience when seeking care, such as reducing waiting time Nepal, China Policy planning • To inform policy planning and implementation through massive health information Philippines, China Government requirement • To meet government requirements Philippines, Kenya Patient–provider communications • To enable better communications between patients and PHC providers China Report and presentation • To have more convenient reporting and presentation of clinical data Philippines, ChinaHealth surveillance • To help consolidate and analyse clinical data to assist health surveillance through dynamic monitoring of clinical data China Table 2.2: Understanding and perceptions of e-health technologies from key informant interviews in China, Nepal, Philippines and Kenya (contd) 32 Benefits and harms of using e-health technologies As is shown in Table 2.3, the interviewees mentioned many areas of benefit of using e-health. The most frequently mentioned benefits were: (i) improved work efficiency and reduced workload for PHC providers by enabling remote communications, accessible data storage and automatic functions; (ii) improved quality, security, readability and accessibility of the storage of clinical data; (iii) improved work accuracy and quality of care enabled by clinical guidance, decisions support, and better patient data storage; (iv) improved continuity of care facilitated because of remote follow-up communications and interventions, better referral systems and timely responses to patients’ health needs enabled by health monitoring; (v) improved patient–provider communication through multimedia tools and remote communications; (vi) improved user experience for PHC providers and patients; and (vii) improvements in the implementation of large-scale health interventions due to the technical advantages of e-health. “It (e-health) makes it easier to explain the patients’ diseases to them. Sometimes, there are illustrations or diagrams that help patients understand their illnesses better.” — PHC providers, Philippines “It (e-health strategies) helps in the supply of medicine, provision of services, or related activities like conducting awareness programmes and prevention programmes…” — Policy-maker, Nepal For themes mentioned in fewer than three of the four countries, some interviewees in Nepal and Kenya reported that e-health reduced people’s financial costs due to improved capacity of PHC facilities, which would stop patients from attending higher-level hospitals and save money from reduced transportation costs. Other notable benefits mentioned by a few interviewees included: increased coverage of health services to underserved populations (Nepal only) and facilitated cross-sectoral collaboration by improved data-sharing and communications (Philippines only). We also identified the harms that participants perceived from using e-health. The most commonly mentioned harm was increased workload for PHC providers caused by poorly designed e-health interventions that 33 required redundant work for data entry and report writing. Another aspect of increased workload was the extra burden from providing online health consulting services, mentioned by one Chinese PHC provider. “I don’t really think the e-health tools reduced our workload. For example, as contracted family doctors, we cannot reply to our patient’s messages during work hours when we have to see patients, so we now have to reply to their question messages beyond working hours.” — PHC provider, China Another mentioned harm from using e-health was the increased vulnerability in service delivery due to an overdependence on ICT, mentioned in China and Kenya. Moreover, some participants in Nepal and Kenya expressed concerns about uninformed "self-treatment" by patients based on the Internet, which might cause health issues. One participant in China mentioned potential health concerns for PHC providers caused by a long-time computer-facing style of work, including eyesight impairment, radiation, and strong lighting. “It would be a total mess when there are issues with the electricity, or the Internet, because now our work is based on them, and that can cause big problems.” — PHC administrator, Kenya “The Google doctor phenomenon where patients access information which they are not able to digest or synthesize led to some of them stopping medication because of what they were reading from the Internet.” — Expert, Kenya Table 2.3: Thematic Table: Benefits and harms of using e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya Themes Key information about each theme Countries Topic: Benefits of the use of e-health technologies at PHC facilities Work efficiency • PHC providers’ improved work efficiency due to remote communications, accessible data storage and automatic functions All 34 Themes Key information about each theme Countries Workload reduction • PHC providers’ workload reduction due to remote communications, accessible data storage and automatic functions All Data storage • Improved quality, security, readability and accessibility of storage of clinical data All Continuity of care • Facilitated continuity of care by enabling remote follow up, patient–provider communications and interventions• Facilitated continuity of care by strengthening provider–provider communications for patients transferred across different health facilities• Facilitated continuity of care by monitoring and surveillance of patients’ health information and receiving timely responses All Patient–provider communication • Enhanced patient–provider communication through multimedia tools• Enhanced patient–provider communication through remote communications All User experience • Improved users’ experience and satisfaction of PHC providers and patients All Work accuracy • Improved work accuracy because of clinical guidance, decision support and patient data storage Nepal, China, Philippines, Quality of care • Improved quality of care due to remote communications, accessible data storage and automatic functions• Reportedly improved health outcomes according to some interviewees (Nepal and Kenya) Nepal, China, Kenya Table 2.3: Thematic Table: Benefits and harms of using e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 35 Themes Key information about each theme Countries Implementation of health interventions • The technical advantages improved the implementation of health interventions Nepal, China, Kenya Reduced financial costs • Reduced financial costs due to improved capacity of PHC facilities, which took patients away from higher-level hospitals and saved money from reduced transportation costs Nepal, Kenya Service coverage • Improved accessibility and coverage of health services to underserved populations Nepal Cross-sectoral collaboration • Facilitated cross-sectoral collaboration by improved data-sharing and communications Philippines Topic: Harms from the use of e-health technologies at PHC Increased workload • Increased workload caused by poorly designed e-health that requires redundant work, such as data entry and report writing• Increased workload caused by online health services Nepal, Philippines, China Overdependence on ICT • Increased vulnerability in service delivery due to overdependence on ICT China, Kenya Uninformed self- doctoring • Patients bypassing professional medical care at the PHC level, and utilizing the internet for self-medication Nepal, Kenya Health concerns for PHC providers • Health concerns based on the time spent in front of screens for PHC providers, including eyesight impairment, radiation and strong lighting China Table 2.3: Thematic Table: Benefits and harms of using e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 36 Facilitators of and barriers to the use of e-health technologies We identified various barriers to, and facilitators of, the use of e-health for NCD service delivery at the PHC level from the interviews (Table 2.4). Many of the barriers and facilitators could be considered in pairs. First, all countries mentioned that political support that encourages and standardizes the use of e-health is an important facilitator, while the current policy gaps are substantial barriers to using e-health. These policy gaps include (i) lack of policy regulations to support the use of e-health technologies, (ii) lack of policy regulations to coordinate the use of e-health technologies across different health sectors, (iii) lack of political guidance to standardize e-health technologies and promote the interoperability of different e-health systems, and (iv) concerns about legal “loopholes” due to lack of formal legislation. “The current market is dominated by e-health systems that are highly fragmented without proper government regulations.” — Policy-maker, Kenya Another frequently mentioned theme was technical availability. The penetration and prevalence of electricity and ICT, particularly cellphones and the Internet, are strong facilitators. However, substantial technical barriers still exist in the following aspects: 1. limited availability and coverage of ICT in resource-limited settings; 2. inequality in technical availabilities in different regions and/or different sectors (e.g. PHC facilities and hospitals), which prohibits integration of service delivery; 3. technical flaws in existing e-health technologies such as instability and unreliability; 4. lack of technical standardization and subsequent incompatibility of different e-health technologies; and 5. technological limitations in some settings, such as inability to establish two-way referral between the PHC facility and hospitals and inability to build a patient interface. “...One of the biggest challenges we’ve been having with this e-health system is the lack of technological advancement and standardization to ensure interoperability.” — Expert, Kenya 37 Third, many PHC providers in all four countries mentioned that their current heavy workload was a barrier to using e-health technologies. Good integration between e-health’s functionality and PHC providers’ routine responsibilities is a facilitator for successful e-health strategies while failing to achieve such integration might cause redundant work and further increase the workload for PHC providers. Fourth, people’s acceptance of ICT, especially among young people, is a facilitator for e-health, while the unacceptance for new technologies, particularly in the older generations, is an important barrier. Fifth, people’s motivation to use e-health is an important factor that influences the successful use of e-health. Of note, one expert in China mentioned the mismatch between e-health and PHC providers’ performance evaluations as an example of failing to motivate PHC providers to use e-health. Sixth, many participants mentioned the adequacy of training provided to e-health users as a critical factor for using e-health, both on the PHC providers’ side and the patients’ side. Seventh, several participants in Philippines, Kenya and China mentioned that having pilot-testing of e-health technologies at their facilities was an important facilitator. Eighth, many participants in Nepal, Philippines and China mentioned that leaders’ endorsement of e-health in local facilities is an important factor that influences the uptake and use of e-health. Ninth, many interviewees in Philippines, Nepal and Kenya, shared a concern about the reduction in necessary physical contact between PHC providers and patients after using e-health. Moreover, some successful experiences were shared by interviewees in China and Philippines. Some mentioned involving diverse stakeholders, especially direct e-health users, in the design of e-health was a strong facilitator. Others reported that high compatibility of different e-health technologies used at the same PHC facilities was helpful for implementing e-health. A third successful experience for using e-health in China and Philippines was the high compatibility of e-health technologies across different health sectors. 38 “When we were initiating the plan (e-health), we invited people of various backgrounds, including doctors, e-health technicians, regional administrative mangers and academic professors, and sought their consultancy regarding the design.” — Expert, China “The establishment of interoperable e-health systems with standardized designs that enable information-sharing across different sectors is being actively pushed by the government.” — Policy-maker, China In contrast to the three scarcely reported factors facilitating successful use of e-health in China and Philippines, many participants in all four countries mentioned the substantial barriers that exist in mainstreaming the use of e-health programmes: 1. lack of users’ involvement in e-health design; 2. lack of standardization and consequently poor compatibility of different e-health technologies even at the same PHC facility; 3. poor compatibility of e-health technologies used at different health sectors (e.g. different PHC facilities, tertiary hospitals, health insurance companies and government departments), which prohibits data transformation and communication; and 4. conflicts of interest across different e-health companies and the subsequent competition and exclusive contracting practices, which compromises the compatibility and unification of e-health technologies. Other less frequently mentioned factors that may influence the use of e-health as facilitators or barriers include sufficiency of funding support, data security, users’ technical literacy and users’ experience with e-health. Notably, several country-specific themes regarding factors influencing the use of e-health emerged. One policy-maker in Nepal shared concerns about potential “national identity issues” related to e-health, given that most current e-health technologies in Nepal were imported from abroad and increased people’s dependency on other countries. One expert from the Philippines mentioned that, in some cases, the compulsive linkage between e-health technologies and insurance schemes served as a facilitator to people’s use of e-health. Another notable mention from the Philippines is that customized designs in response to the local capacity 39 (e.g. Internet connectivity) was an important facilitator. One Chinese interviewee mentioned that negative patient–provider relationships prohibited the optimal use of e-health technologies, and one Nepali interviewee mentioned that there were language barriers in using e-health at multilingual settings. “Right now, we don’t have the ability to build it from scratch. Let’s hope that in the future, we don’t be completely dependent on it (other countries)... Those data should be in our country and we should be able to use it… Nowadays the issue of national identity is trending. So, the issues regarding data storage are a big deal.” — Policy-maker, Nepal Table 2.4: Thematic table: barriers to, and facilitators of, the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya Themes Key information about each theme Countries Topic: Facilitators for the use of e-health technologies at PHC settings Political support • Policies that support and standardize the use of e-health technologies All Technological availability • The penetration and prevalence of electricity and information and communication technologies (ICT), particularly cellphones and the Internet All People’s acceptance • People’s acceptance of and support for the use of ICT in general, especially among the young generation All People’s motivation and incentives • The motivation and incentives to use e-health for both patients and PHC providers All Personnel training • Training provided to PHC providers in using e-health with regard to their routine responsibilities• Training provided to patients to use e-health for their disease management and health- care-seeking behaviours All Pilot experience • Pilot-testing of e-health technologies Philippines, Kenya, China 40 Themes Key information about each theme Countries Users’ involvement in e-health design • Involving diverse stakeholders, especially users, in the design phase of e-health (few reports) Philippines, China Data security • The guaranteed security of patients’ health information Philippines, China, Kenya Leadership support • Endorsement for e-health from leaders of each institution Nepal, Philippines, China Combination with insurance schemes • The combination between e-health technologies and insurance schemes Philippines Funding support • Sufficient funding support for e-health technologies from different sources, including the government, industry and society China, Kenya Technical support • Timely and high-quality technical support of designated IT technicians for the implementation and maintenance of e-health technologies Philippines Timely updates • Developers’ timely updates of and improvements to e-health technologies based on process evaluations and users’ feedback China Localized design • Designs localized to the contexts, such as offline functions where Internet connectivity is limited:• “Facilities with connectivity problem can do offline encoding (and then) regions can upload it online (when the connection is good).” (Policy-maker, Philippines) Philippines Integration with routine responsibilities • High integration between e-health technologies and PHC providers’ routine responsibilities Philippines, China Compatibility of different e-health technologies • High compatibility of different e-health technologies within one PHC facility Philippines, China Table 2.4: Thematic table: barriers to, and facilitators of, the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 41 Themes Key information about each theme Countries Compatibility of e-health across different health sectors • High compatibility of e-health technologies between PHC facilities and other health sectors (e.g. different PHC facilities, tertiary hospitals, health insurance companies and government departments) Philippines, China Topic: Barriers to the use of e-health technologies in PHC settings Policy gaps • Lack of policy regulations to support the use of e-health technologies• Lack of policy regulations to coordinate the use of e-health across different health sectors• Lack of political guidance to standardize e-health technologies and to promote the interoperability of different e-health systems• Concerns about legal “loopholes” due to lack of formal legislation All Technical barriers • Limited availability and coverage of ICT in resource-limited settings, including issues with Internet connectivity, electricity and cellphones• Inequality in technical availabilities of different regions and/or different sectors (e.g. PHC facilities and hospitals), which prohibits integration of service delivery• Technical flaws in existing e-health technologies such as instability and unreliability• Lack of technical standardization and subsequent incompatibility of different e-health technologies• Technological limitations in some settings, such as inability to establish two-way referral between PHC facilities and hospitals, and inability to build a patient interface All Insufficient funding • Insufficient funding to initiate and scale up e-health in resource-limited settings• Insufficient funding for long-term maintenance of e-health technologies All Table 2.4: Thematic table: barriers to, and facilitators of, the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 42 Themes Key information about each theme Countries Lack of cross- sectoral coordination and communications • Lack of coordination among different sectors, including different levels of government, health sector and private organizations• Lack of communication among different e-health companies All People’s lack of acceptance • Lack of acceptance for e-health and resistance to change, especially among older generations• Regional disparities in people’s unacceptance, especially in less developed regions All Technical illiteracy • Lack of readiness and capacity to use ICT among both patients and PHC providers, which may cause communication barriers during training and usage All Lack of users’ involvement in e-health design • PHC’s lack of involvement in the design of e-health• Neglect for and/or inability to address users’ feedback Philippines, China Conflicts of interest • The competition/exclusiveness of different e-health companies Philippines, China, Kenya National identity issues • Concerns regarding national identity issues due to technology dependency on other countries Nepal Data security issues • Concerns regarding private companies exploiting user data and violating confidentiality• Concerns regarding compromised data security when information is shared across different facilities and departments through e-health• Concerns regarding bureaucracies and misuse of people’s information in government sectors Nepal, Kenya, China Lack of leadership support • Lack of consensus in leadership support for using e-health Nepal Concerns about reduction in physical contact • Concerns about e-health interventions replacing physical contact and face-to-face communication between patients and providers and causing trust issues Philippines, Kenya, Nepal Table 2.4: Thematic table: barriers to, and facilitators of, the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 43 Themes Key information about each theme Countries PHC providers’ high workload • Heavy workload of PHC provider with other responsibilities apart from e-health All Language barriers • Language barriers in multilingual settings Nepal Inadequate personnel training • Lack of training of PHC providers in using e-health technologies• Inability to deliver personnel training on e-health technologies Nepal, Kenya, Philippines Negative user experience • Negative user experience and unfriendliness of e-health due to design failures or technical flaws, such as long loading time and occasional system breakdowns All Patient–provider relationship • Negative patient–provider relationships that prohibit optimal use of e-health technologies China Mismatch with personnel evaluation • The mismatch between e-health and PHC providers’ performance evaluations China Poor integration with routine responsibilities • Poor integration between e-health technologies and PHC providers’ routine responsibilities Nepal, Kenya, Philippines Poor compatibility of different e-health technologies • Lack of standardization and consequently poor compatibility of different e-health technologies even in the same PHC facility Philippines, China, Kenya Poor compatibility of e-health across different health sectors • Lack of standardization and consequently poor compatibility of e-health technologies used at different health sectors (e.g. different PHC facilities, tertiary hospitals, health insurance companies and government sectors), which prohibits data transformation and communication All Table 2.4: Thematic table: barriers to, and facilitators of, the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 44 Suggestions to improve the use of e-health technologies Abundant suggestions were proposed by the interviewees to improve the use of e-health technologies for NCD service delivery at PHC settings (Table 2.5). Many of the suggestions were to address the barriers to or enhance facilitators for the use of e-health, which were summarized in the previous section. The suggestions could be categorized into four main domains: (i) suggestions about political support and coordination; (ii) suggestions regarding technology development; (iii) suggestions for PHC facilities at the local level; and (iv) suggestions targeted at PHC providers and patients. For suggestions regarding political support and coordination, stakeholders in all four countries mentioned the need to prioritize policies that support the use of e-health technologies so that PHC facilities can use them routinely. There was also mention of standardizing and increasing interoperability of different e-health technologies as well as facilitating cross-sectoral collaboration in both the design and implementation phases of e-health technologies, including among different health sectors (PHC facilities, hospitals), government sectors, health insurance companies and private organizations. “It really depends on the leaders and the government. There need to be policies, and they need to mobilize different e-health companies for research and development, to coordinate different departments to manage and surveil……They need to integrate all these, and it is going to take much effort in communications.” — PHC administrator, China Regarding technology development, which was the second most mentioned area, stakeholders mentioned the need to improve various technical domains, including functionality, security, coverage, stability, affordability and user experience; and to combine different e-health applications into integral platforms that enable multiple functions. They acknowledged that this would require the creation of unified technical standards and guidelines that facilitate the interoperability of different e-health technologies. They also believed that there is a need for user- centred design and improved user-friendliness for e-health, by involving frontline users in the design phase, which would include PHC providers and patients. 45 “It would be great to combine functions such as PHC providers’ performance evaluation, personnel training, organizing facility-wise meetings, and even external academic communication, with a single e-health system. Basically, I mean combining health service delivery and educational service delivery together, on the PHC providers’ side.” — PHC administrator, China “(e-health) Projects can be successful if we can identify the needs and work on those needs after considering its feasibility and then scalability……” — Expert, Nepal With regard to e-health at PHC facilities, the most frequently mentioned recommendation was to conduct i) local needs assessment before initiating and/or scaling up e-health technologies, ii) local capacity assessment when designing and implementing e-health technologies (i.e. electricity and Internet stability and availability), and iii) local cultural context assessment to customize e-health design (e.g. local languages). Other notable suggestions for local PHC facilities are included in Table 2.5. Finally, suggestions that targeted individual e-health users were around training of users and incentivizing the use of e-health in order to enhance user's long-term adherence. One policy-maker from China proposed the combination of e-health technologies and PHC providers’ performance evaluation as one example of a non-financial incentive for using e-health. Table 2.5: Thematic table: Suggestions to improve the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya Themes Key information about each theme Countries Topic: Suggestions for political support and coordination Political support • To prioritize policies that support the use of e-health technologies• To have long-term planning for policy regulations that standardize the use of e-health across different health sectors and to enable communications• To promote compatibility of different e-health technologies All 46 Themes Key information about each theme Countries Cross-sectoral collaboration • To facilitate cross-sectoral collaboration among different stakeholders in the design and implementation of e-health technologies, including different health sectors, government sectors, health insurance companies and social organizations• To facilitate collaboration between public and private health facilities on the use of e-health to enable information- sharing and patient referral All Financial support • To increase financial support for developing and implementing e-health from multiple sources: government, industry and society Philippines, Nepal Advertisement • To document, analyse and present to the public the impact of e-health technologies to increase their acceptability and to promote and replicate successful cases Nepal Topic: Suggestions for technology development Technology development • To facilitate technological development for e-health technologies to enhance their functionality, security, coverage, stability, affordability and user experience• To create integral e-health platforms that combine different e-health applications within the same facility• To create unified technical standards and guidelines that facilitate the compatibility and interoperability of different e-health technologies All Table 2.5: Thematic table: Suggestions to improve the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 47 Themes Key information about each theme Countries User-centred design • To adopt a user-centred design and improve user-friendliness• To foster communications between e-health developers and users, and to actively involve frontline users in the design phase, including PHC providers and patients All Offline services • To promote offline e-health technologies in regions where Internet connectivity is an issue• To have an offline e-health server as a back-up plan Philippines, Kenya Empirical research • To conduct rigorous research and/or pilot research to determine the optimal design of e-health and how to integrate e-health into the PHC system Nepal Topic: Suggestions for PHC facilities Local assessment • To identify local needs before initiating and/or scaling up e-health technologies• To assess local capacities when designing/implementing e-health (e.g. Internet access)• To assess local cultural contexts to customize e-health design, such as local languages All Technical support • To hire designated ICT technicians to assist with e-health practices and technical issues Philippines, China, Kenya Pilot-testing • To conduct pilot-testing when aiming to promote larger-scale e-health interventions Kenya Programme evaluation • To conduct continuous evaluation of e-health programmes and identify recurrent issues Nepal Table 2.5: Thematic table: Suggestions to improve the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 48 Themes Key information about each theme Countries Local initiation • To facilitate the initiation of e-health technologies at the local level Nepal Involving community health workers • To involve community health workers in the implementation of e-health technologies Nepal Institutionalization • To institutionalize the use of e-health technologies instead of it being project- based only Nepal Young workforce • To ensure an adequate proportion of a young workforce in PHC-related institutions who are more likely to be good at ICT Nepal Topic: Suggestions for PHC providers and patients Education and training • To raise awareness of and provide education and training on e-health technologies on the users’ side for both patients and PHC providers All Incentives and motivation • To provide financial and/or non- financial incentives to patients and PHC providers for using e-health• To combine e-health-related practices with PHC providers’ performance evaluations Nepal, China User adherence • To emphasize users’ adherence to the proper use of e-health technologies over time Philippines Discussion Researchers and health-care practitioners have long acknowledged the importance of PHC in providing accessible, affordable and high- quality care, and in combating the substantial and increasing burden from NCDs. The Primary Health Care Performance Initiative, a global partnership initiative founded in 2015 by the Bill & Melinda Gates Foundation, WHO and the World Bank Group, indicated that a strong Table 2.5: Thematic table: Suggestions to improve the use of e-health technologies for noncommunicable disease service delivery in primary health-care settings from key informant interviews in China, Nepal, Philippines and Kenya (contd) 49 PHC system should be able to provide a high quality of care in a way that ensures first-contact availability, continuity, comprehensiveness, safety and coordination of patient care throughout the course of treatment and across various sites [15]. However, existing studies, including our previous APO-funded study, identified major barriers that prohibited PHC from providing optimal care for NCD patients [3]. As an emerging and innovative strategy, e-health has the potential to strengthen PHC in ways that are both economically viable and sustainable, especially in improving service delivery [16]. There have been an increasing number of studies on e-health for health practices in various aspects, including, but not limited to, maternal and child health, infectious disease management and NCD management [17–20]. There has also been a surge in the innovation of new e-health applications that target multiple types of users, including PHC providers and patients [21]. The increasingly prevalent use of e-health was confirmed by our research in the four countries, where most of our interviewees were aware of and highly supportive of such uses. In line with existing studies, the most commonly mentioned purposes of using e-health were to improve the efficiency and quality of care, improve patient experiences and inform policy planning [22]. Evidence on the effectiveness of current e-health strategies in addressing the mentioned purposes, however, is not adequate. Existing research mainly studied three types of outcomes of using e-health strategies: clinical outcomes, behavioural outcomes and implementation outcomes. The effectiveness of e-health in improving health outcomes is highly mixed, and some papers attributed the mixed results to limitations in study design, such as limited sample size and short follow-up times [23, 24]. However, e-health’s effectiveness has demonstrated promise in improving people’s behavioural outcomes, especially when substantiated by behaviour science theories [6, 25]. Moreover, many studies found e-health effective in implementation outcomes, such as improving user experience [26], feasibility and fidelity of health interventions [7], and increasing reach and coverage of health services in underserved populations [27, 28]. The different levels of effectiveness across clinical, behavioural and implementation outcomes from using e-health implies that e-health is a promising tool to strengthen the implementation of health-care service delivery even in settings with low resources and can be utilized for population-level behavioural change interventions. However, its ultimate effectiveness in improving people’s health/clinical outcomes 50 depends largely on the rigour of its design and implementation, which needs to be navigated through various facilitators and barriers. Various facilitators and barriers exist in the use of e-health, both according to the existing literature and our qualitative research. The most prominent factor is political support. Although all the four MICs in our study – China, Nepal, Philippines and Kenya – have shown increasing political commitment to enhancing e-health strategies in recent years, there are still major policy gaps for e-health, including poor governance and lack of regulations to support and standardize the use of e-health technologies across the different health sectors. Nonetheless, the drastic technological development in recent decades has led to high penetration and prevalence of ICT, which has become a critical driver for the development and implementation of e-health strategies [29, 30]. However, the unavailability, instability and unreliability of e-health technologies and the associated infrastructure, especially in resource-limited settings, are still important barriers to the optimal use of e-health for NCD service delivery at the PHC level. In addition, people’s mistrust of e-health technologies due to concerns over privacy violation and lack of legal enforcement was also found in existing studies [31]. At the local facility level and individual user level, various barriers prohibit the optimal use of e-health. Insufficient personnel training, lack of integration between e-health and PHC providers’ routine responsibilities, poor design of e-health technologies that cause redundant work and increase workload for PHC providers, and lack of motivation and incentives for PHC providers and NCD patients to adhere to the use of e-health were commonly reported across the four countries, which is consistent with existing studies on e-health [32, 33]. To address these predominant barriers, one of the most important solutions proposed by many participants is to conduct comprehensive local assessments, which include: 1. assessment of local needs, particularly involving PHC providers in the e-health design to address their real-life needs and incorporate e-health into their routine work and performance evaluations; 2. assessment of local capacities, including infrastructure capacity and people’s technical literacy; and 3. assessment of local cultures, and customization of the e-health technologies to the local context such as language and people’s education level. 51 Two literature reviews on readiness assessment for e-health identified similar relevant factors that needed to be assessed when implementing e-health strategies, but they found that most existing studies focused on capacity assessment only, while a “few assessed government and societal readiness, and none cultural readiness” [34]. Our study concurs with this observation and adds to the literature that it is critical to conduct prospective assessments to align e-health strategies with local needs and to customize these with local cultural contexts to facilitate the use of e-health at PHC settings. The present study has many strengths. First, the scoping review of the relevant literature in both the English and Chinese languages provided contexts for the research topic, which informed the qualitative research protocol. Second, for the qualitative research, although limited in scope, the identification and selection of various stakeholders from four diverse MICs in Asia and Africa with different economic development status, health systems and e-health applications, increased the relevance of the study. However, our study has some limitations. Due to the diversity of health systems and the different status of e-health development of the four selected countries, there were challenges in standardizing the qualitative research protocol across different countries. The study team tried to mitigate these challenges by enabling local collaborators to make adjustments to the research protocol based on local contexts. In summary, as highly innovative tools are enabled by the rapid development of ICTs, e-health technology shows great promise in strengthening PHC service delivery and combating the NCD disease burden. Future research is warranted to corroborate the findings of our study. First, we call for rigorous trials and systematic reviews to gather definitive evidence about the effectiveness of e-health technologies on the three types of outcomes for NCD control (i.e. clinical, behavioural and implementation outcomes). 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Telemed J E Health. 2013;19(4):241–7. [29] De Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long- term illnesses. Cochrane Database Syst Rev. 2012;12(12):CD007459. [30] Beratarrechea A, Diez-Canseco F, Irazola V, Miranda J, Ramirez- Zea M, Rubinstein A. Use of m-health technology for preventive interventions to tackle cardiometabolic conditions and other non-communicable diseases in Latin America – challenges and opportunities. Prog Cardiovasc Dis. 2016;58(6):661–73. [31] Jacomet C, Ologeanu-Taddei R, Prouteau J, Lambert C, Linard F, Bastiani P, et al. Adoption and attitudes of e-health among people living with HIV and their physicians: online multicenter questionnaire Study. JMIR mHealth uHealth. 2020;8(4):e16140. [32] Lee YK, Ng CJ, Low WY. Addressing unmet needs of patients with chronic diseases: impact of the VISIT website during consultations. J Eval Clin Pract. 2017;23(6):1281–8. [33] El-Gayar O, Timsina P, Nawar N, Eid W. A systematic review of IT for diabetes self-management: are we there yet? Int J Med Inform. 2013;82(8):637–52. [34] Mauco KL, Scott RE, Mars M. Critical analysis of e-health readiness assessment frameworks: suitability for application in developing countries. J Telemed Telecare. 2018;24(2):110–7. 56 Appendices Appendix 1: Search syntax for the scoping review in three literature sources 1. For English databases, we searched for “title/abstract” OR “keywords” by the following terms: (“ehealth” OR “electronic health” OR “e-health” OR “mhealth” OR “mobile health” OR “m-health” OR “digital health” OR “dhealth” OR “d-health” OR “telehealth” OR “teletherapy” OR “tele-therapy” OR “tele-intervention” OR “teleintervention” OR “telecare” or “tele-care” OR “EHR” OR “electronic health record” OR “electronic medical record” OR “EMR” OR “blood pressure monitoring” OR “bp monitoring” OR “information communication technology” OR “ICT” OR “short- message service” OR “sms” OR “smart phone” OR “cell phone” OR “cell-phone” OR “feature phone” OR “mobile phone” OR “telephone” OR “app” OR “wireless health” or “healthcare technology” OR “medical information system” OR “telemonitoring” OR “tele-monitoring” OR “telepresence” OR “tele-presence” OR “electronic health information” OR “teleconsultation” OR “tele-consultation” OR “e-rehabilitation” OR “personal digital assistant”) AND (“PHC” OR “primary health care” OR “primary healthcare” OR “primary care” OR “primary health” OR “basic healthcare” OR “essential healthcare” OR “healthcare at the grassroot level”) AND (“hypertension” OR “HTN” OR “blood pressure” OR “diabetes” OR “heart disease” OR “stroke” OR “cerebrovascular disease” OR “CVD” OR “cardiovascular disease” OR “non-communicable” OR “NCD” OR “chronic disease” OR “non-infectious disease” OR 57 “cardiometabolic disease” OR “CMD” OR “cardiometabolic condition” OR “cardiometabolic patient” OR “metabolic syndrome”) 2. For the literature search on the official websites of international health- related organizations, we included the same search terms as above but excluded the second group of keywords related with “primary healthcare”, because of the limited number of results when we put in this group. 3. For Chinese databases, we searched for “title/abstract” OR “keywords” by the following terms: 题名:((((“互联网” OR “智慧” OR “智能” OR “电子” OR “移动” OR “便携” OR “远程” OR “数字” OR “数位” OR “信息” OR “无线” OR “短信” OR “微信” OR “手机” OR “ 掌上电脑” OR “交互” OR “个人数码助理” OR “APP” OR “应用程序” OR “可穿戴 设备” OR “电话” )) AND (“健康” OR “医疗” OR “医学” OR “诊疗” OR “治疗” OR “照护” OR “看护” OR “监测” OR “病历” OR “健康档案” OR “医院” OR “卫生” OR “干预” OR “随访”)) AND (“血压” OR “糖尿病” OR “心脏病” OR “冠心病” OR “心血管疾病” OR “中风” OR “卒中” OR “脑血管疾病” OR “非传染性疾病” OR “慢性病” OR “慢病” OR “心脏 代谢病” OR “心血管代谢病” OR “代谢综合征”)) AND (“初级卫生保健” OR “初级保健” OR “初级医疗” OR “初级卫生服务”OR “基 本卫生保健” OR “基本保健” OR “基本医疗” OR “基本卫生服务” OR “基础卫生保 健” OR “基础保健” OR “基础卫生服务” OR “基础医疗” OR “基层医疗” OR “基层 卫生保健” OR “基层保健” OR “基层卫生” OR “基层卫生服务” OR “社区医疗” OR “初级健康” OR “基本健康” OR “基础健康”)) 58 Appendix 2: Listing of included papers from the scoping review by study types 2.1 Review Articles 1. Kim BY, Lee J. Smart Devices for Older Adults Managing Chronic Disease: A Scoping Review. Jmir Mhealth and Uhealth. 2017;5(5). 2. Byambasuren O, Sanders S, Beller E, Glasziou P. Prescribable mHealth apps identified from an overview of systematic reviews. Npj Digital Medicine. 2018;1. 3. de Jongh T, Gurol-Urganci I, Vodopivec-Jamsek V, Car J, Atun R. Mobile phone messaging for facilitating self-management of long-term illnesses. Cochrane Database of Systematic Reviews. 2012(12). 4. El-Gayar O, Timsina P, Nawar N, Eid W. A systematic review of IT for diabetes self-management: Are we there yet? International Journal of Medical Informatics. 2013;82(8):637-52. 5. Agarwal R, Bills JE, Hecht TJW, Light RP. Role of Home Blood Pressure Monitoring in Overcoming Therapeutic Inertia and Improving Hypertension Control A Systematic Review and Meta-Analysis. Hypertension. 2011;57(1):29-U139. 6. Beishuizen CRL, Stephan BCM, van Gool WA, Brayne C, Peters RJG, Andrieu S, et al. Web-Based Interventions Targeting Cardiovascular Risk Factors in Middle-Aged and Older People: A Systematic Review and Meta-Analysis. Journal of Medical Internet Research. 2016;18(3). 7. Beratarrechea A, Diez-Canseco F, Irazola V, Miranda J, Ramirez-Zea M, Rubinstein A. Use of m-Health Technology for Preventive Interventions to Tackle Cardiometabolic Conditions and Other Non-Communicable Diseases in Latin America- Challenges and Opportunities. Progress in Cardiovascular Diseases. 2016;58(6):661-73. 8. Watkins JA, Goudge J, Gomez-Olive FX, Huxley C, Dodd K, Griffiths F. mHealth text and voice communication for monitoring people with chronic diseases in low-resource settings: a realist review. Bmj Global Health. 2018;3(2). 9. Zapata BC, Fernández-Alemán JL, Idri A, Toval A. Empirical studies on usability of mHealth apps: a systematic literature review. Journal of medical systems. 2015 Feb 1;39(2):1. 59 10. Wang Y, Xue H, Huang Y, Huang L, Zhang D. A systematic review of application and effectiveness of mHealth interventions for obesity and diabetes treatment and self-management. Advances in Nutrition. 2017 May;8(3):449-62. 11. Buhi ER, Trudnak TE, Martinasek MP, Oberne AB, Fuhrmann HJ, McDermott RJ. Mobile phone-based behavioural interventions for health: A systematic review. Health Education Journal. 2013 Sep;72(5):564-83. 12. Bloomfield GS, Vedanthan R, Vasudevan L, Kithei A, Were M, Velazquez EJ. Mobile health for non-communicable diseases in Sub-Saharan Africa: a systematic review of the literature and strategic framework for research. Globalization and health. 2014 Dec 1;10(1):49. 13. Hsu J, Liu D, Yu YM, Zhao HT, Chen ZR, Li J, Chen W. The top Chinese mobile health apps: a systematic investigation. Journal of Medical Internet Research. 2016;18(8):e222. 14. Njoroge M, Zurovac D, Ogara EA, Chuma J, Kirigia D. Assessing the feasibility of eHealth and mHealth: a systematic review and analysis of initiatives implemented in Kenya. BMC research notes. 2017 Dec;10(1):1-1. 15. Kebede MM, Liedtke TP, Möllers T, Pischke CR. Characterizing active ingredients of eHealth interventions targeting persons with poorly controlled type 2 diabetes mellitus using the behavior change techniques taxonomy: scoping review. Journal of medical Internet research. 2017;19(10):e348. 16. Jensen L, Troster SM, Cai K, Shack A, Chang YJ, Wang D, Kim JS, Turial D, Bierman AS. Improving heart failure outcomes in ambulatory and community care: a scoping study. Medical Care Research and Review. 2017 Oct;74(5):551-81. 17. Lewis J, Ray P, Liaw ST. Recent worldwide developments in eHealth and mHealth to more effectively manage cancer and other chronic diseases–a systematic review. Yearbook of medical informatics. 2016 Aug;25(01):93-108. 18. Nhavoto JA, Grönlund Å. Mobile technologies and geographic information systems to improve health care systems: a literature review. JMIR mHealth and uHealth. 2014;2(2):e21. 60 19. Baron J, McBain H, Newman S. The impact of mobile monitoring technologies on glycosylated hemoglobin in diabetes: a systematic review. Journal of diabetes science and technology. 2012 Sep;6(5):1185-96. 20. Marcolino MS, Oliveira JA, D’Agostino M, Ribeiro AL, Alkmim MB, Novillo-Ortiz D. The impact of mHealth interventions: systematic review of systematic reviews. JMIR mHealth and uHealth. 2018;6(1):e23. 21. Hou C, Carter B, Hewitt J, Francisa T, Mayor S. Do mobile phone applications improve glycemic control (HbA1c) in the self-management of diabetes? A systematic review, meta-analysis, and GRADE of 14 randomized trials. Diabetes care. 2016 Nov 1;39(11):2089-95. 22. Miller L, Schüz B, Walters J, Walters EH. Mobile technology interventions for asthma self-management: systematic review and meta-analysis. JMIR mHealth and uHealth. 2017;5(5):e57. 23. Müller AM, Alley S, Schoeppe S, Vandelanotte C. The effectiveness of e-& mHealth interventions to promote physical activity and healthy diets in developing countries: a systematic review. International Journal of Behavioral Nutrition and Physical Activity. 2016 Dec;13(1):109. 24. Cajita MI, Gleason KT, Han HR. A systematic review of mHealth-based heart failure interventions. The Journal of cardiovascular nursing. 2016 May;31(3):E10. 25. Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bulletin of the World Health Organization. 2012;90:357-64. 26. 赵燕萍. 信息化基础的慢性病“三位一体”管理模式的应用研究. 中国全科医 学. 2012;15(7). 27. 陈林利, 严玉洁, 方红, 张金玲, 汤军克, 赵燕萍. 基于信息化的医防结合高血 压防治模式研究及效果分析. 中国初级卫生保健. 2015;29(2):63-5. 2.2 Experiment Studies 1. Leon N, Surender R, Bobrow K, Muller J, Farmer A. Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial. BMC family practice. 2015;16:80. 61 2. Fernandes BSM, Reis IA, Torres HD. Evaluation of the telephone intervention in the promotion of diabetes self-care: a randomized clinical trial. Revista Latino-Americana De Enfermagem. 2016;24. 3. Kleczka B, Musiega A, Rabut G, Wekesa P, Mwaniki P, Marx M, et al. Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low- resource settings. International Journal of Medical Informatics. 2018;114:121-9. 4. Bobrow K, Farmer A, Cishe N, Nwagi N, Namane M, Brennan TP, et al. Using the Medical Research Council framework for development and evaluation of complex interventions in a low resource setting to develop a theory-based treatment support intervention delivered via SMS text message to improve blood pressure control. BMC health services research. 2018;18(1):33. 5. Diehl LA, Souza RM, Gordan PA, Esteves RZ, Coelho ICM. InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians. Journal of Medical Internet Research. 2017;19(3). 6. Santos MVR, Oliveira DC, Novaes Mde A. A Telehealth Strategy for Increasing Adherence in the Treatment of Hypertension in Primary Care. Telemedicine and E-Health. 2013;19(4):241-7. 7. Ajay VS, Jindal D, Roy A, Venugopal V, Sharma R, Pawar A, et al. Development of a Smartphone-Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence-Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project. Journal of the American Heart Association. 2016;5(12). 8. Silveira DV, Marcolino MS, Alkmim MB, Ferreira CG, Machado E, Couto B, et al. Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility. JMIR mhealth and Uhealth. 2016;7(3). 9. Liew SM, Tong SF, Lee VKM, Ng CJ, Leong KC, Teng CL. Text messaging reminders to reduce non-attendance in chronic disease follow-up: A clinical trial. British Journal of General Practice. 2009;59(569):916- 20. 10. Maia JX, De Sousa LAP, Marcolino MS, Cardoso CS, Da Silva JLP, Alkmim MBM, et al. The impact of a clinical decision support system in diabetes 62 primary care patients in a developing country. Diabetes Technology and Therapeutics. 2016;18(4):258-63. 11. Nascimento BR, Beaton AZ, Nunes MCP, Tompsett AR, Oliveira KKB, Diamantino AC, et al. Integration of echocardiographic screening by non-physicians with remote reading in primary care. Heart. 2018. 12. Varleta P, Akel C, Acevedo M, Salinas C, Pino J, Garcia A, et al. Mobile phone text messaging improves antihypertensive drug adherence in the community. Journal of Clinical Hypertension. 2017;130. 13. Visanuyothin S, Plianbangchang S, Somrongthong R. An integrated program with home blood-pressure monitoring and village health volunteers for treating poorly controlled hypertension at the primary care level in an urban community of Thailand. Integrated Blood Pressure Control. 2018;11:25-35. 14. Lee YK, Ng CJ, Low WY. Addressing unmet needs of patients with chronic diseases: Impact of the VISIT website during consultations. Journal of Evaluation in Clinical Practice. 2017;23(6):1281-8. 15. Abdullah A, Othman S. The influence of self-owned home blood pressure monitoring (HBPM) on primary care patients with hypertension: a qualitative study. BMC family practice. 2011;12:143. 16. Nakashima N, Hiramatsu T, Ghosh PP, Islam R, Kobayashi K, Inoguchi T. Evaluation of “Portable Health Clinic” with BAN standard for 10K subjects in Bangladesh. Conference proceedings : Annual International Conference of the IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine and Biology Society Annual Conference. 2013;2013:1672-5. 17. 丁宏健, 陈秉初, 白鹤, 蒋蓓, 夏芬娟, 赵妍妍, et al. 实施高血压社区综合干预 信息化管理规范中期效果评估报告. 中国初级卫生保健. 2008;22(11):16-7. 18. 池捷. 区域性临床医疗与健康档案信息交互共享平台的建立和应用. 中国卫 生信息管理杂志. 2009(2). 19. 郭望英. 电话网络心电模式在社区基础医疗的应用. 中国临床药理学与治疗 学. 2012;17(6). 20. 李迥. 远程家庭康复指导与脑梗死患者康复效果. 中国康复医学杂志. 2012;27(6). 21. 顾亚琴. 信息化技术在高血压管理中的应用及效果评价. 中国初级卫生保健. 2014;28(11):55-69. 63 22. 徐彩文, 曾艳红. 电话访视制度在社区慢性病患者护理中的应用. 中国初级卫 生保健. 2014;28(7):135-6. 23. 许克玲, 章爱萍. 基于微信平台的延续性护理模式对2型糖尿病患者影响的 研究. 中国初级卫生保健. 2016;30(12):85-7. 24. 陈娇. 基于微信平台的健康促进随访模式在脑卒中合并吞咽障碍患者中的 应用. 中国医药导报. 2017;14(7). 25. 戴国强, 戴家强. 微信健康教育平台对社区糖尿病患者血糖控制的影响分析. 中国初级卫生保健. 2017;31(4):49-51. 26. 林小凤. 远程心电、血压检测系统对社区慢性病患者疾病监控效果的影响 研究. 中国实用医刊. 2017;44(14). 27. 王文祥. 移动医疗D2C模式在基层社区高血压病管理中的应用研究. 中华全 科医学. 2017;15(7). 28. 金琦. 微信平台结合家庭医生签约服务在社区高血压患者治疗中的作用. 中 国初级卫生保健. 2018;32(3):44-6. 29. 李星明. 可穿戴健康监测设备在社区高血压患者管理中的应用效果评价. 中 华健康管理学杂志. 2018;12(4). 30. 励艳艳. 基层社区血脂异常干预信息化平台效果评价. 医药前沿. 2018;8(1):349-50. 31. 饶慧兰. 微信健康教育对社区青年高血压患者的干预效果研究. 中外医学研 究. 2018;16(3). 32. 徐小花, 徐雪明, 卫家芬. 信息化医院—社区综合防治管理在社区2型糖尿病 患者管理中的应用. 中国初级卫生保健. 2018;32(11):26-8. 33. 周亚芬, 蒋晓金. 基于微信平台的延续性护理干预在中老年糖尿病足患者自 我管理行为中的应用. 中国初级卫生保健. 2018;32(9):83-4. 2.3 International Organization Documents 1. World Health Organization. Telemedicine: opportunities and developments in member states. Report on the second global survey on eHealth. World Health Organization; 2010. 2. World Health Organization. mHealth: new horizons for health through mobile technologies. mHealth: new horizons for health through mobile technologies.. 2011. 3. Jakab M, Farrington J, Bogermans L, Mantingh F. Health systems respond to noncommunicable diseases: time for ambition. WHO Regional Office for Europe; 2018. 64 4. World Health Organization. Digital health. Draft resolution proposed by Algeria, Australia, Brazil, Estonia, Ethiopia, Germany, India, Indonesia, Israel, Italy, Luxembourg, Mauritius, Morocco, Panama, Philippines, and South Africa. 71st World Health Assembly agenda item. 2018 May 25;12:A71. 5. World Health Organization. Global diffusion of eHealth: making universal health coverage achievable: report of the third global survey on eHealth. World Health Organization; 2017 Mar 27. 6. World Health Organization. Atlas of EHealth Country Profiles: The Use of EHealth in Support of Universal Health Coverage: Based on the Findings of the Third Global Survery on EHealth 2015. World Health Organization; 2016 Jun 22. 7. World Health Organization. WHO compendium of innovative health technologies for low resource settings, 2011-2014: assistive devices, eHealth solutions, medical devices, other technologies, technologies for outbreaks. World Health Organization; 2015. 8. Alkmim MB, Figueira RM, Marcolino MS, Cardoso CS, Abreu MP, Cunha LR, Cunha DF, Antunes AP, Resende AG, Resende ES, Ribeiro AL. Improving patient access to specialized health care: the Telehealth Network of Minas Gerais, Brazil. Bulletin of the World Health Organization. 2012;90:373-8. 9. Kwankam SY. Successful partnerships for international collaboration in e-health: the need for organized national infrastructures. Bulletin of the World Health Organization. 2012;90:395-7. 10. Braa J, Heywood A, Sahay S. Improving quality and use of data through data-use workshops: Zanzibar, United Republic of Tanzania. Bulletin of the World Health Organization. 2012;90:379-84. 11. Piette JD, Lun KC, Moura Jr LA, Fraser HS, Mechael PN, Powell J, Khoja SR. Impacts of e-health on the outcomes of care in low-and middle- income countries: where do we go from here?. Bulletin of the World Health Organization. 2012;90:365-72. 12. Lewis T, Synowiec C, Lagomarsino G, Schweitzer J. E-health in low-and middle-income countries: findings from the Center for Health Market Innovations. Bulletin of the World Health Organization. 2012;90:332- 40. 65 13. Mair FS, May C, O’Donnell C, Finch T, Sullivan F, Murray E. Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review. Bulletin of the World Health Organization. 2012;90:357-64. 14. International Telecommunications Union. Information and Telecommunications/ICTs for e-Health 2017 [cited 2020. Available from: https://www.itu.int/pub/D-STG-SG02.02.2-2017. 15. International Telecommunications Union. Be He@lthy-Be Mobile (A handbook on how to implement mBreatheFreely) 2018 [cited 2020. Available from: https://www.itu.int/pub/D-STR-E_HEALTH.12. 16. International Telecommunications Union. Be He@lthy-Be Mobile (A handbook on how to implement mDiabetes) 2018 [cited 2020. Available from: https://www.who.int/ncds/prevention/be-healthy- be-mobile/hanbook-mDiabetes/en/. 17. International Telecommunications Union. Be He@lthy-Be Mobile (A handbook on how to implement mTobaccoCessation) 2018 [cited 2020. Available from: https://www.who.int/ncds/prevention/be- healthy-be-mobile/handbooks-mTobaccoCessation/en/. 18. International Telecommunications Union. Be He@lthy-Be Mobile (A handbook on how to implement mAgeing) 2018 [cited 2020. Available from: https://www.who.int/ageing/health-systems/mAgeing/en/. 19. World Health Organization. Be he@lthy, be mobile: annual report 2018 2019 [Available from: https://apps.who.int/iris/bitstream/han dle/10665/326497/9789241516259-eng.pdf. 20. Otto K, Shekar M, Herbst CH, Mohammed R. Information and Communication Technologies for Health Systems Strengthening 2015 [Available from: https://openknowledge.worldbank.org/bitstream/ handle/10986/21710/949430WP0ICT0f00Box385445B00PUBL IC0.pdf;sequence=1. 21. Le Pape MA, Suárez JC, Mhayi A, Haazen D, Özaltin E. Developing an HMIS Architecture Framework to Support a National Health Care eHealth Strategy Reform: A Case Study from Morocco. Health Systems & Reform. 2017 Jan 2;3(1):56-67. 22. Shekar M, Otto K. ICTs for health in Africa 2014 [cited 2020. Available from: https://agris.fao.org/agris-search/search. do?recordID=US2014606225. 66 23. Guislain P, Ampah MA, Besancon L, Niang C, Serot A. Connecting Sub- Saharan Africa: A World Bank Group strategy for information and communication technology sector development. The World Bank; 2005 May 10. 24. Ramamurthy A, Serrat O. Developing e-Health Capabilities in Bhutan 2014 [cited 2020. Available from: https://www.think-asia.org/ handle/11540/416. 25. Thit WM, Parry J. Digital Health Convergence Meeting Tool Kit. Asian Development Bank; 2018 Nov 1. 26. Jones T, Drury P, Zuniga P, Roth S. Digital Health Impact Framework User Manual 2018 [cited 2020. Available from: https://www.think- asia.org/handle/11540/9046. 27. Tabor SR, Yoon SY. Promoting information and communications technology in Indonesia 2015 [Available from: https://www.adb.org/ publications/promoting-ict-indonesia. 28. Roth S, Parry J, Landry M. Universal health coverage by design: ICT-enabled solutions are the future of equitable, quality health care and resilient health systems 2015 [Available from: https:// www.adb.org/publications/universal-health-coverage-by-design? utm_source=feedburner&utm_medium=feed&utm_campaign= Feed%3A+adb_publications+(ADB.org+Publications+RSS). 67 Appendix 3: Semi-structured interview guide for the qualitative research Part I: Background information about the interviewee 1. What is your professional background? 2. What are your current responsibilities? 3. How many years have you been working in this field? Part II: Basic information about the facility 1. The number of doctors, nurses, and other personnel 2. The number of beds 3. The number of residents covered 4. The number of daily/annual outpatients 5. The number of annual discharged inpatients Part III: Definition of e-health The definition of e-health given by the WHO is “the use of information and communication technologies for health.” Based on your understanding and work experience, do you agree with this definition? If not, please give us your modified definition of e-health. (Please make sure that after this question, the interviewer and the interviewee are on the same page about what e-health is.) Part IV: The design, uptake, and maintenance of e-health technologies in the facility 1. What e-health technologies are available in your facility? 2. What are the purposes of using those e-health technologies? (E.g. reducing workload burden, improving efficiency/accuracy) 3. Currently, what is the role of PHC facilities in the whole life cycle of e-health technologies, from initiation, design, uptake, to maintenance? What do you think SHOULD be the role? 68 4. What are the factors that influence the uptake of the e-health technologies? (Can use some specific examples of the existing e-health technologies) 5. What are the facilitators and barriers for the use of e-health in your facility? (E.g. financial, technical, and personnel factors) 6. Are there issues in maintaining using e-health in your facility? What are they? (E.g. financial, technical, and personnel factors) Part V: Integration of e-health to the PHC system for NCD service delivery (Please emphasize that our research focuses on the service delivery for patients with hypertension and diabetes.) 1. What do you think is an ideal situation where e-health technologies are well integrated in the PHC practices for NCDs? Integration of e-health with interviewee’s routine responsibilities 2. In what aspects of your job responsibilities involve e-health technologies? 3. What are the effects of using these e-health technologies on your work? Both positive and negative effects. 4. How do you think e-health can better fit in your responsibilities? (E.g. better design and functions) 5. Based on the considerations above, what is your overall attitude towards the use of e-health technology? 6. If any, what are your concerns for using e-health technology in NCD management? (For respondents who expressed reservations about their attitudes toward e-health in the previous question, please pay extra attention to this question.) Integration of different e-health technologies in one primary health facility 1. Is there any connection between the different e-health technologies used in your facility? (For example, in some medical facilities, diagnosis, medical reports, information archives, and medical insurance data, are all based on one integral system.) 69 2. How do you think the different e-health technologies in your facility can be better integrated and compatible with each other? Integration of e-health applications across different primary health facilities 1. To your knowledge, what are some typical/distinctive cases of successful uses of e-health for NCD in other PHC facilities? 2. Are the e-health technologies in your facility different from other PHC facilities in the same city? What are the differences? 3. If any, what are the effects of these differences in the collaboration and communication among different facilities? (E.g. patient referrals, information sharing) 4. How to enhance the integration of e-health technologies among different primary healthcare facilities? Integration of e-health applications between primary healthcare facilities with other non-PHC facilities 1. According to your knowledge, are there other non-PHC facilities that use e-health technologies? What are they like? (E.g. secondary/tertiary hospitals, companies, disease control centers, and governmental departments) 2. Can the e-health applications in your facility be integrated with these other departments? (E.g. patient referrals, and information sharing) 3. How do you think we can enhance the integration of e-health technologies among PHC facility and non-PHC facilities? Part VI: Suggestions for e-health 1. What is the future development strategy in your facility regarding the use of e-health technologies, especially for hypertension and diabetes management? 2. What are your other suggestions to better integrate e-health to the PHC system for NCD service delivery? (If the interviewee considers the problem too broad, interviewer can guide them to answer it at the policy level, facility level, and individual level.) 70 Appendix 4: Profile of participants of the qualitative research Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition China: 3 policymakers, 5 experts, 6 PHC administrators, 6 PHC providers, and 7 NCD patients National Policymaker Male Primary care and health technology 3 NA Regional Policymaker Male Primary care and NCDs 10 NA Regional Policymaker Female Primary care and NCDs 5 NA Expert Male Health informatics 8 NA Expert Male Health informatics 5 NA Expert Male Biomechanical engineering NA NA Expert Female General practice 3 NA Expert Female Primary care 20 NA Facility 1: administrator Male Clinical medicine 11 NA Facility 1: provider Male Integrated traditional Chinese and Western medicine 11 NA Facility 1: NCD patient Male NA NA NA Facility 2: administrator Female Clinical medicine 24 NA Facility 2: provider Female Clinical medicine 4 NA Facility 2: NCD patient Male NA NA NA Facility 3: administrator Female Clinical medicine 20 NA Facility 3: provider Female Nursing 6 NA 71 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 3: NCD patient Male NA NA NA Facility 4: administrator Female Integrated traditional Chinese and Western medicine 7 NA Facility 4: provider Female Clinical medicine 3 NA Facility 4: NCD patient Male NA NA NA Facility 5: administrator Male Clinical medicine 14 NA Facility 5: provider Female Integrated traditional Chinese and Western medicine 2 NA Facility 5: NCD patient Male NA NA NA Facility 5: NCD patient Female NA NA NA Facility 6: administrator Male Clinical medicine 18 NA Facility 6: provider Male Preventative medicine 2 NA Facility 6: NCD patient Male NA NA NA Nepal: 4 policymakers, 5 experts, 6 PHC administrators, 6 PHC providers, and 6 NCD patients National Policymaker Male Health policy and public health NA NA Regional Policymaker Male Public health and immunization NA NA Regional Policymaker Male Public health NA NA Regional Policymaker Male Public health NA NA Appendix 4: Profile of participants of the qualitative research (contd) 72 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Expert Male Cardio-thoracic surgery, Cardio- metabolic disease prevention NA NA Expert Male Cardio-metabolic disease prevention NA NA Expert Male eHealth and public health NA NA Expert Male eHealth NA NA Expert Male NCD and mental health NA NA Facility 1: administrator Female General medical practice, PHC 6 NA Facility 1: provider Female General medical practice, PHC 3.5 NA Facility 1: NCD patient Male NA NA Hypertension, diabetes Facility 2: administrator Male General medical practice, PHC 27 NA Facility 2: provider Male General medical practice, PHC 5 NA Facility 2: NCD patient Female NA NA Hypertension Facility 3: administrator Female Primary healthcare 20 NA Facility 3: provider Female General medical practice, PHC 0.5 NA Facility 3: NCD patient Female NA NA Hypertension Facility 4: administrator Female Primary healthcare 25 NA Facility 4: provider Female Primary healthcare 25 NA Appendix 4: Profile of participants of the qualitative research (contd) 73 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 4: NCD patient Female NA NA diabetes Facility 5: administrator Female Primary healthcare 23 NA Facility 5: provider Female Primary healthcare 7 NA Facility 5: NCD patient Female NA NA Hypertension Facility 6: administrator Female Primary healthcare 24 NA Facility 6: provider Male General medical practice, PHC 2 NA Facility 6: NCD patient Male NA NA diabetes The Philippines: 3 policymakers, 5 experts, 6 PHC administrators, 18 PHC providers, and 18 NCD patients National Policymaker Female Department of health 20+ NA Regional Policymaker Male Regional health office 10+ NA Regional Policymaker Male local health IT administrator 10+ NA Expert Male IT, Standards, Interoperability 20+ NA Expert Male Primary care and NCDs 30+ NA Expert Female Academics 20+ NA Expert Male Administrator/IT developer 20+ NA Expert Female Government branch, research/project management 10+ NA Appendix 4: Profile of participants of the qualitative research (contd) 74 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 1: administrator Male Supervisor/Nurse < 5 NA Facility 1: provider Female Nurse < 5 NA Facility 1: provider Female Pharmacist < 5 NA Facility 1: provider Male Doctor < 5 NA Facility 1: NCD patient Female NA NA Hypertension Facility 1: NCD patient Female NA NA Diabetes Facility 1: NCD patient Female NA NA Hypertension, diabetes Facility 2: administrator Female Supervisor/ Pharmacist < 5 NA Facility 2: provider Male Nurse < 5 NA Facility 2: provider Female Nurse < 5 NA Facility 2: provider Male Doctor < 5 NA Facility 2: NCD patient Female NA NA Hypertension Facility 2: NCD patient Female NA NA Diabetes Facility 2: NCD patient Male NA NA Hypertension Facility 3: administrator Female Supervisor/Nurse < 5 NA Facility 3: provider Female Nurse < 5 NA Facility 3: provider Female Nurse < 5 NA Facility 3: provider Male Doctor < 5 NA Facility 3: NCD patient Female NA NA Hypertension Facility 3: NCD patient Female NA NA Diabetes Appendix 4: Profile of participants of the qualitative research (contd) 75 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 3: NCD patient Female NA NA Diabetes Facility 4: administrator Female head of doctors 15~20 NA Facility 4: provider Female Nurse < 5 NA Facility 4: provider Female Midwife 20~30 NA Facility 4: provider Female Midwife 10~15 NA Facility 4: NCD patient Female NA NA Other NCDs Facility 4: NCD patient Male NA NA Hypertension, diabetes Facility 4: NCD patient Female NA NA Hypertension Facility 5: administrator Female head of doctors 25~30 NA Facility 5: provider Male Dentist 10~15 NA Facility 5: provider Female Midwife 25~30 NA Facility 5: provider Female Nurse 20~25 NA Facility 5: NCD patient Female NA NA Other NCDs Facility 5: NCD patient Female NA NA Other NCDs Facility 5: NCD patient Female NA NA Other NCDs Facility 6: administrator Female head of doctors 20~25 NA Facility 6: provider Female Community health worker 5~10 NA Facility 6: provider Male IT encoder < 5 NA Facility 6: provider Female Nurse 10~15 NA Appendix 4: Profile of participants of the qualitative research (contd) 76 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 6: NCD patient Male NA NA Other NCDs Facility 6: NCD patient Male NA NA Hypertension Facility 6: NCD patient Male NA NA Hypertension Kenya: 3 policymakers, 5 experts, 6 PHC administrators, 6 PHC providers, and 6 NCD patients National Policymaker Male Medical 0fficer & Public health specialist 22 NA Regional Policymaker Female Pediatrics 14 NA Regional Policymaker Male Pharmacy 9 NA Expert Male Medical officer 18 NA Expert Female Health records and information management officer 22 NA Expert Female Primary care and NCDs 10 NA Expert Female Clinical medicine 9 NA Expert Male Psychiatry 10 NA Facility 1: administrator Female Clinical officer 11 NA Facility 1: provider Female Nurse 6 NA Facility 1: NCD patient Female NA NA NA Facility 2: provider Female Nurse 5 NA Facility 2: NCD patient Female NA NA NA Facility 3: administrator Female Nurse 4 NA Appendix 4: Profile of participants of the qualitative research (contd) 77 Type of Interviewee Gender Professional Background Years at the Position / in this Field Health condition Facility 3: provider Female Clinical nutritionist 3 NA Facility 3: NCD patient Female NA NA NA Facility 4: administrator Male Medical officer 12 NA Facility 5: administrator Female Clinical officer 41 NA Facility 5: provider Male Clinical officer 1 NA Facility 5: NCD patient Male NA NA NA Facility 6: administrator Female Dentist 9 NA Facility 6: provider Female Nurse 6 NA Facility 6: NCD patient Female NA NA NA Facility 7: administrator Female Clinical officer 20 NA Facility 7: provider Male Clinical officer 20 NA Facility 7: NCD patient Female NA NA NA Appendix 4: Profile of participants of the qualitative research (contd) 78 Ap pe nd ix 5 : P ro fil e of se le ct ed p rim ar y h ea lth ca re fa ci lit ie s f or th e qu al ita tiv e re se ar ch Re gi on /N at ur e of Fa ci lit y # of d oc to rs # of n ur se s O th er h ea lth p er so nn el # of be ds # of re si de nt s co ve re d # of d ai ly ou tp at ie nt s # of a nn ua l di sc ha rg ed in pa tie nt Ch in a W uh an 21 35 • 4 me di ca l t ec hn ic ia ns • 5 ph ar m ac is ts 31 85  8 90 > 10 0 N A ( cu rr en tl y no t ta ki ng in pa ti en ts ) W uh an 35 28 • 7 me di ca l t ec hn ic ia ns • 11 o th er p er so nn el 40 71  0 00 37 0 65 W uh an 74 16 8 • 14 m ed ic al te ch ni ci an s 99 15 9  37 6 45 0 31 19 Sh en zh en 13 9 • 3 me di ca l t ec hn ic ia ns 0 23  8 56 26 0 0 Sh en zh en 11 7 • 7 me di ca l t ec hn ic ia ns 0 25  0 00 27 0 0 Sh en zh en 13 9 • 11 m ed ic al te ch ni ci an s 0 38  0 00 25 0 0 N ep al K av re pa la nc ho w k 1 0 • 1 au xi lia ry h ea lt h w or ke rs ( A H W ) • 1 au xi lia ry n ur se m id w ife ( A N M ) • 1 Se ni or A N M 0 17 51 20 ~ 25 N A 79 Re gi on /N at ur e of Fa ci lit y # of d oc to rs # of n ur se s O th er h ea lth p er so nn el # of be ds # of re si de nt s co ve re d # of d ai ly ou tp at ie nt s # of a nn ua l di sc ha rg ed in pa tie nt K av re pa la nc ho w k 0 0 • 2 he al th a ss is ta nt s • 1 sen io r A N M • 1 sen io r A H W • 2 AN M s • 1 AH W • 1 ad m in is tr at or 0 60 00 10 N A K av re pa la nc ho w k 1 pe rm an en t 3 te m po ra ry 0 • 3 AN M s • 1 he al th a ss is ta nt • 2 sen io r A H W s • 1 lab te ch ni ci an 3 48 00 20 ~ 22 24 K at hm an du 0 0 • 1 pu bl ic h ea lt h of fi ce r • 1 sen io r A N M • 1 AH W 1 63 00 0 10 ~ 15 N A K at hm an du 0 0 • 1 pu bl ic h ea lt h of fi ce r • 1 AH W 1 50 0~ 70 00 15 ~ 16 N A K at hm an du 2 4 • 1 he al th a ss is ta nt • 3 AH W s • 1 lab te ch ni ci an 0 16 00 0 15 N A Ap pe nd ix 5 : P ro fil e of se le ct ed p rim ar y h ea lth ca re fa ci lit ie s f or th e qu al ita tiv e re se ar ch (c on td ) 80 Re gi on /N at ur e of Fa ci lit y # of d oc to rs # of n ur se s O th er h ea lth p er so nn el # of be ds # of re si de nt s co ve re d # of d ai ly ou tp at ie nt s # of a nn ua l di sc ha rg ed in pa tie nt Th e Ph ili pp in es Pu bl ic 1 2 • 1 de nt is t • 3 mi dw iv es • 1 me di ca l t ec hn ic ia n • 5 com m un it y he al th w or ke rs • 1 lab te ch ni ci an • 1 ad m in is tr at or N A 10 2  01 3 18 0 N A Pu bl ic 1 1 • 1 de nt is t • 3 mi dw iv es • 1 me di ca l t ec hn ic ia n • 4 com m un it y he al th w or ke rs • 1 lab te ch ni ci an • 1 ad m in is tr at or N A 34  0 59 55 ~ 12 0 N A Pu bl ic 1 1 • 1 de nt is t • 3 mi dw iv es • 1 me di ca l t ec hn ic ia n • 5 com m un it y he al th w or ke rs • 1 lab te ch ni ci an • 1 ad m in is tr at or N A 87  4 87 29 0~ 32 0 N A Ap pe nd ix 5 : P ro fil e of se le ct ed p rim ar y h ea lth ca re fa ci lit ie s f or th e qu al ita tiv e re se ar ch (c on td ) 81 Re gi on /N at ur e of Fa ci lit y # of d oc to rs # of n ur se s O th er h ea lth p er so nn el # of be ds # of re si de nt s co ve re d # of d ai ly ou tp at ie nt s # of a nn ua l di sc ha rg ed in pa tie nt Pr iv at e 4 5 • 1 ph ar m ac is t N A 12  5 00 40 ~ 50 N A Pr iv at e 3 4 • 1 ph ar m ac is t N A 10  0 00 30 ~ 40 N A Pr iv at e 3 3 • 1 ph ar m ac is t N A 78 00 20 ~ 30 N A Ke ny a N A 1 1 • - 50 0 15 N /A N A 7 23 • 20 N /A 15 00 10 0 N /A N A 1 25 • 18 16 55 00 0 50 30 00 N A 2 2 • 1 N /A 10 00 10 0 N /A N A 5 15 • - 5 32 00 0 14 5 10 20 N A 3 12 • - 24 35 00 11 0 35 0 Ap pe nd ix 5 : P ro fil e of se le ct ed p rim ar y h ea lth ca re fa ci lit ie s f or th e qu al ita tiv e re se ar ch (c on td ) Asia Pacific Observatory on Health Systems and Policies (APO) publications to date Health System in Transition (HiT) review (19 countries) • The Fiji Islands (2011) • The Philippines (2011; 2018) • Mongolia (2013) • Malaysia (2013) • New Zealand (2014) • Lao People’s Democratic Republic (2014) • The Republic of the Union of Myanmar (2014) • Solomon Islands (2015) • The Kingdom of Cambodia (2015) • Bangladesh (2015) • Republic of Korea (2015) • The Kingdom of Thailand (2015) • The Kingdom of Tonga (2015) • People’s Republic of China (2015) • The Republic of Indonesia (2017) • The Kingdom of Bhutan (2017) • Japan (2018) • Independent State of Papua New Guinea (2019) • Sri Lanka (2021) Policy brief (13 series) • Direct household payments for health services in Asia and the Pacific (2012) • Dual practice by health workers in South and East Asia (2013) • Purchasing arrangements with the private sector to provide primary health care in underserved areas (2014) • Strengthening vital statistics systems (2014) • Quality of care (2015) • The challenge of extending universal coverage to non-poor informal workers in low- and middle- income countries in Asia (2015) • Factors conducive to the development of health technology assessment in Asia (2015) • Attraction and retention of rural primary health- care workers in the Asia-Pacific region (2018) • Use of community health workers to manage and prevent noncommunicable diseases (2019) • Strategies to strengthen referral from primary care to secondary care in low- and middle-income countries (2019) • ASEAN mutual recognition arrangements for doctors, dentists and nurses (2019) • Strengthening primary health care for the prevention and management of cardiometabolic disease in LMICs (2019) • Overseas medical referral: the health system challenges for Pacific Island Countries (2020) HiT policy notes (four countries) • The Republic of the Union of Myanmar (2015) #1 What are the challenges facing Myanmar in progressing towards universal health coverage? #2 How can health equity be improved in Myanmar? #3 How can the township health system be strengthened in Myanmar? #4 How can financial risk protection be expanded in Myanmar? • The Kingdom of Cambodia (2016) Increasing equity in health service access and financing: health strategy, policy achievements and new challenges • The Kingdom of Thailand (2016) Health system review: achievements and challenges • Bangladesh (2017) Improving the quality of care in the public health system in Bangladesh: building on new evidence and current policy levers Comparative country studies (seven series) • Public hospital governance in Asia and the Pacific (2015) • Case-based payment systems for hospital funding in Asia: an investigation of current status and future directions (2015) • Strategic purchasing in China, Indonesia and the Philippines (2016) • Health system responses to population ageing and noncommunicable diseases in Asia (2016) • Resilient and people-centred health systems: progress, challenges and future directions in Asia (2018) • Moving towards culturally competent, migrant- inclusive health systems: a comparative study of Malaysia and Thailand (2021) • Integrated care for chronic diseases in Asia Pacific countries (2021) The APO publications are available at www.healthobservatory.asia

POLICY BRIEF Vol. 8, No. 1 2021 POLICY BRIEF Use of e-health programmes to deliver urban primary health-care services for noncommunicable diseases in middle-income countries The Asia Paci�ic Observatory on Health Systems and Policies is a collaborative partnership which supports and promotes evidence-informed health policy making in the Asia Paci�ic Region. Based in WHO’s Regional Of�ice for South-East Asia, it brings together governments, international agencies, foundations, civil society and the research community with the aim of linking systematic and scienti�ic analysis of health systems in the Asia Paci�ic Region with the decision-makers who shape policy and practice. 978 92 9022 903 2