6. The digital transformation of primary health care in Brazil

There is a comprehensive push for a digital PHC in Brazil

The importance of connecting and digitalizing PHC practices is clear and the potential value added would be very significant (see Box 6.2). Digital health can help PHC be the first point of contact with patients, co-ordinate referrals and follow-up to secondary and tertiary care, and monitor and keep track of community and population-level health risks and conditions (Castle-Clarke and Imison, 2016[7]). The COVID-19 pandemic has made clear there are enormous benefits to digitalising and connecting health care facilities and services.

The potential benefits of a digital transformation of PHC are also clear in the context of Brazil’s National Health Plan 2020-23 (Ministério da Saúde, 2020[6]). Among its objectives are to promote the expansion and effectiveness of PHC services in an integrated and planned fashion, to guarantee access to quality PHC services for all, and to reduce population health risks through prevention, epidemiological surveillance and health promotion.

Brazil has a long history of developing, implementing and using health information systems (Ministério da Saúde, 2017[10]). In 2017, the government launched a public tender, the Primary Health Unit Computerisation Programme, to support the country’s PHC units in using electronic health record (EHR) systems by enhancing connectivity, acquiring ICT equipment, and providing technical support and training of health professionals (OECD, 2020[11]). Following concerns from the Federal Court of Accounts regarding the viability of a national rollout, the programme was replaced by Connect SUS. Connect SUS seeks to bring together all the health information of any one citizen under a large data network that can be used to continuously improve health care and decision making. The Connect SUS programme depends on two essential elements: the RNDS and the updated Primary Health Unit Computerisation Programme (Programa de Apoio à Informatização e Qualificação dos Dados da Atenção Primária à Saúde or Informatiza APS).

Through the Connect SUS programme, and as part of the Previne Brasil programme, the Informatiza APS programme provides federal funding (between USD 330 or BRL 1 700 and USD 388 or BRL 2000 per month) to family health teams that are able to collect and send data from electronic health record (EHR) systems (Harzheim et al., 2020[12]). The programme includes the provision of training in ICT and data analysis to public employees in municipal health departments (CGI.br, 2020[13]). The training is jointly organised by the Ministry of Health and the University of Rio Grande do Sul. It consists of 60 hours of training delivered through Telehealth Centres. In order to qualify for support from Informatiza APS, family health teams need to have already made investments in digital technologies, have a working EHR system and be able to share data through the PHC Health Information System (the Sistema de Informação em Saúde para a Atenção Básica or SISAB). Those teams that are eligible may use the funds from Informatiza APS to acquire software or hardware, pay for Internet connectivity in UBS, and hire ICT services, among others.

A key eligibility requirement of the Informatiza APS programme is that family health units need to already be using digital technologies. However, Connect SUS ran a pilot project in the state of Alagoas between October 2019 and June 2020 that did include an additional financial incentive for PHC units that have not yet been able to digitalise (Ministério da Saúde, 2020[14]). The Alagoas pilot provided a lump sum of between USD 1 649 (BRL 8 500) and USD 1 940 (BRL 10 000) to each municipality in Alagoas for every PHC unit that was not yet digitalised (more than USD 1.07 million or BRL 5.5 million were disbursed to 97 municipalities). In light of the COVID-19 pandemic, the Ministry of Health instituted a time-limited incentive of USD 5 268 (BRL 27 157) to be paid to municipalities and states for each health team that has not yet been digitalised (see Box 6.3). The Ministry of Health is also collaborating with the Ministry of Science, Technology, Innovation and Communications, with support from the National Education and Research Network (Rede Nacional de Ensino e Pesquisa or RNP), to provide Internet connectivity to 16 000 PHC facilities (CGI.br, 2020[13]).

A key element of Connect SUS focusing specifically in PHC is the e-SUS APS strategy (or Estratégia e-SUS APS, often also referred to as e-SUS AB for Atenção Básica) which seeks to modernise PHC through the use of health information systems, in order to better manage individual health and care, optimise data collection and improve health information (Ministério da Saúde, 2020[6]). The strategy is based on two underlying data collection systems: the simplified data collection system (Coleta de Dados Simplificada) and the EHR system (Prontuário Eletrônico do Cidadão or PEC). Around 56% of family health units that have been digitalised use the PEC, while others use third-party EHR systems (Ministério da Saúde, 2020[14]).

The Informatics Department of SUS – typically referred to as DATASUS – has also made various other applications available to citizens, frontline care workers and health care managers (CGI.br, 2020[13]). These include: MedSUS, an application that lists all medications approved for use in SUS; e-Gestor AB, a platform that combines multiple PHC information systems to facilitate the planning and delivery of health services; and the Conecte SUS Cidadão app, which builds on a previous version called Meu digiSUS¸ which allows citizens to access their personal and clinical data collected from multiple national registries as well as access useful information, such as where are the closest health care facilities and pharmacies. There are also versions of Conecte SUS for frontline health workers (Conecte SUS Profissional) as well as managers.

Another interesting system is DigiSUS Gestor – Módulo Planejamento (DGMP), a tool made available to states, the Federal District and municipalities in May of 2019. The DGMP allows local managers to register population health targets, annual plans, produce and send reports to the National Health Council, as well as produce annual reports. The Ministry of Health also makes available an Application Programming Interface, or API, that allows different software platforms used by health care facilities to integrate their EHR systems with the RNDS, as well as make use of blockchain solutions.

Municipalities are also increasingly providing digital services to citizens (CGI.br, 2020[13]). For example, the São Paulo prefecture has developed an app called Agenda Fácil which allows patients to book, confirm and cancel consultations and examinations in the municipality’s PHC units. According to the latest ICT Electronic Government Survey (2020[15]), 25% of Brazilian prefectures allow patients to book appointments online and in some cases to be consulted via the Internet.

Start-ups in telemedicine are also becoming increasingly relevant. Brasil Telemedicina, founded in 2010, offers online medical services. It produces around 60 000 reports per month and has clients in more than 700 Brazilian cities (Brasil Telemedicina, 2020[16]). Another startup, Telelaudo, provides tele radiology services 24 hours a day, seven days a week, and employs 120 radiologists. It has provided more than 4.7 million reports to more than 450 hospitals (Telelaudo, 2021[17]).

Reliable energy supply and fast connectivity are indispensable

Appropriate electricity supply and Internet connectivity are vital. As discussed, a significant number of PHC units do not have an Internet connection and a majority have speeds that are likely insufficient to make simultaneous use of EHR systems, high-quality video consultations and remote patient monitoring. Among the main barriers to digitalisation reported by 12 municipalities in the context of the recent pilot project in Alagoas were unreliable electricity supply and a lack of sufficiently fast broadband (Ministério da Saúde, 2020[14]). In some cases, there were no broadband suppliers (ibid). A 2018 study of 91 electricity suppliers serving 81 million households, found the quality of supply varies across regions, with citizens in remote localities, like the Amazonas, having significantly less stable electricity than someone living in São Paulo (Idec, 2018[21]).

Brazil’s geography (nearly eight times the size of France and Spain combined) and sparsely distributed population are certainly challenging for inclusive connectivity (OECD, 2020[22]). The Brazilian Digital Transformation Strategy (E-Digital), along with the Connected Brazil programme, have been instrumental in expanding broadband connectivity (OECD, 2020[11]). Yet, connectivity targets have focused exclusively on schools and have not made explicit mention of concrete connection speeds or reliability. Brazil could explore how rural co-operatives might help bring stable electricity supply and affordable broadband, as done in North Dakota, and build on private sector efforts to connect rural populations in Peru (see Box 6.4).

Remote and rural municipalities face significant barriers to dependable and fast connectivity, as well as a stable energy supply. These locations often have more limited resources yet face higher costs from broadband suppliers than better resourced large municipalities in urban areas. Partnerships between the Ministry of Health, the Ministry of Science, Technology and Innovation and the Ministry of Defence to connect PHC units, especially in remote locations, are crucial. It is important to evaluate the impact of these initiatives. For example, the already mentioned programme under the RNP that aims to connect 16 000 primary health units is limited to 12 months and does not seem to set concrete targets in terms of connection speeds or reliability. Without adequate Internet connectivity, the poorest and most remote regions of Brazil will be further left behind, with a digital transformation at national level compounding rather than reducing existing regional inequalities.

Purely financial incentives can be helpful but capacity building is still a major barrier

The Connect SUS pilot project in Alagoas provided municipalities with up to USD 1 940 (BRL 10 000) per unconnected PHC unit (Ministério da Saúde, 2020[14]). Despite this, in the period under evaluation, digitalisation in Alagoas lagged behind the average in the Northeast region as well as the overall Brazilian average (ibid). There is no question that financial support is needed to help PHC units and municipalities acquire essential ICT products and services. Yet, the results in Alagoas show financial support alone is not enough. One of the barriers to digitalisation reported by the 12 municipalities in Alagoas was the lack of an implementation team (Ministério da Saúde, 2020[14]).

It is not only digital skills among health care workers that matter, but also the skills, time and ownership needed to drive digitalisation of PHC units. The Alagoas pilot planned to conduct capacity-building workshops in three regions in the State, but due to COVID-19 ended up conducting workshops in only one region. That region (the 1ª Região de Saúde de Alagoas) was responsible for half of the total increase in digitalisation during the pilot. The workshop trained professionals from 19 municipalities on the installation and use of the e-SUS AB EHR system (PEC) and other e-SUS software, as well as training those professionals attending how they themselves could train their colleagues. Another key activity in the workshop was to establish the timeline and responsibilities for implementation of the EHR system. While there are other reasons for the success of the 1ª Região de Saúde de Alagoas, such as high degree of urbanisation, it is likely that the capacity-building workshop had a positive impact.

It is not just health care workers but also crucially managers that lead digitalisation of care services. In England, since 2017, the NHS Digital Academy has been training clinical and information technology leaders to support the digital transformation of the NHS. The Academy is delivered through a partnership between Imperial College London, the University of Edinburgh and the Harvard Medical School (Socha-Dietrich, 2021[25]). Its flagship Digital Health Leadership programme combines content in leadership and change management, health informatics and data analytics, health systems and user centred design, as well as citizen informatics, among other subjects. In Brazil, the implementation of the Programa Educacional em Saúde Digital is a step in the good direction. The programme was instituted in 2020 by the Secretaria de Gestão do Trabalho e da Educação na Saúde and in partnership with the Federal University of Goiás. In 2021, the programme includes specialisation in digital health for both health care workers and health managers at States and Municipal levels.

As mentioned, the EHR system is at the core of digital PHC. It is impossible to send out vaccination alerts, to suggest therapies based on clinical records, and to predict clinical outcomes when patient records are not digitalised. As seen, the large majority of health care facilities, especially smaller PHC practices, do not have decision support and information exchange capabilities within their EHR systems. However, Brazil has shown it is capable of making rapid progress. In just three years (2016-19), the share of public health care facilities with EHR systems capable of (CGI.br, 2020[13]): listing every lab result a patient has had increased from 17% to 41%; listing every patient that is using a specific pharmaceutical went from 18% to 40%; electronic drug prescribing increased from 29% to 51%. These are key functionalities in support of PHC, especially when it is estimated that the purpose of one in five medical appointments is not clinical but to ask for prescriptions and certificates (Mendes, 2011[26]; Marshall, Shah and Stokes-Lampard, 2018[27]). Tying financing of digital PHC to the use of specific functionalities can be a powerful way to increase adoption (more on this in section 6.4.2).

Digital divides mirror social inequalities limiting effective digital PHC provision

There is a clear association between digital and social inequalities in Brazil (see Figure 6.3). Despite important increases in connectivity, nearly 47 million Brazilians did not use the Internet in 2019 (CGI.br, 2020[29]). Among non-users, the large majority had lower education (85%) and lower socio-economic status or SES (95% belonged to classes C and DE2). Furthermore, regional disparities in use persist. The difference between the proportion of connected households in the Southeast (75%) and the Northeast (65%) regions is of 10 percentage points (ibid). According to the most recent ICT Households Survey (2020[29]), close to 20 million Brazilian households did not have Internet access in 2019, of which 6.4 million households were from the Northeast region. Households with the lowest SES made up the majority of households without Internet access (13 million households in classes DE did not have access in 2019). In 2019, nearly 35 million were disconnected in urban areas (23%) and 12 million in rural areas (47%).

Figure 6.3. There are important digital divides in Internet access at home

Share of households with broadband Internet access at home, 2020

Note: Differences in methodology for income in Korea, Brazil and the United States, and for rural/urban in the United States only. Data on income for Brazil, the United States, Costa Rica and France are for 2019; data on rurality for Brazil, the United States, France, the United Kingdom and Switzerland are for 2019. For Brazil specifically, the data are collected by CETIC. Income data are collected using ranges in minimum wages. Reported data were aggregated in a way that best fit the distribution into four balanced categories. Income non-response are not included. Areas are defined as urban or rural according to local legislation, as compiled by the NSO. Reported data refer to urban (densely populated) and rural (thinly populated).

Source: OECD ICT Access and Usage by Households and Individuals (database), http://stats.oecd.org/Index.aspx?DataSetCode=ICT_HH2.

As mentioned, in 2019, 40% of Internet users in Brazil searched for information on health or health care services online (CGI.br, 2020[29]). The share of individuals seeking health information on the Internet was lower among those aged 60 years and older, as well as in groups with lower SES (classes DE). Only 23% of Internet users searched for or used public health services (CGI.br, 2020[29]).

While Brazil has made significant progress in implementing digital government services, certain groups of individuals are not taking full advantage. According to the 2019 ICT Household Survey (2020[29]), those less likely to use e-government services include people aged 60 years and older (46% use e-government services compared to 75% of 25 to 34-year-olds), those with lower education levels (46% of those with elementary education compared to 87% of those with tertiary education), and those from groups with lower SES (48% in classes DE compared to 88% in class A).

Digital inclusiveness as a foundation for digital PHC for all

Brazil’s policies for digital inclusion have focused on bringing the Internet to remote areas and isolated communities (OECD, 2020[11]). This is the case with the Electronic Government – Citizen Assistance Service (Governo Eletrônico – Serviço de Atendimento ao Cidadão or GESAC) programme, created in 2002 to provide free broadband Internet connections to telecentres, schools, health care units as well as indigenous villages and socially vulnerable communities (OECD, 2018[1]). Other programmes3 include the Digital Inclusion Programme, the Connected Citizen Project, the One Computer Per Student Project and the Telecentros.BR Programme (OECD, 2018[1]). The Internet for All (Internet para Todos) programme is a more recent expansion of the GESAC, focusing on subsidising broadband connections for the more than 30 000 localities and districts in Brazil without a connection.

The creation of telecentres throughout Brazil in the 2000s was one of the first initiatives at the federal level to promote digital inclusion (CGI.br, 2020[31]). Telecentres are public spaces that provide computers with an Internet connection free for anyone to access, as well as workshops, courses and training. According to the most recent ICT Public Access Centres 2019 Survey, which gathers information on telecentres, 45% of telecentres were not operational in the three months prior to the data collection, the most cited reason being a lack of computers and Internet connection, followed closely by lack of maintenance and financial resources (CGI.br, 2020[31]). The number of telecentres in use decreased from the previous Survey in 2013, one possible reason being that the original telecentre programme stipulated that after an initial five-year period of support by the federal government, the equipment would be donated to the municipalities (OECD, 2020[11]).

In 2015, the Federal Audit Office (Tribunal de Contas da União) reviewed public policies related to digital inclusion, finding difficulties in the co-ordination of the different levels of government, limited previous studies to inform and frame new policies and actions, and no systematic monitoring and evaluation of programmes (Tribunal de Contas da União, 2015[32]). In 2018, the Federal Audit Office again drew attention to the lack of co-ordination across the federal, state and municipal governments, and pointed out that many municipalities do not have any telecentres (Tribunal de Contas da União, 2018[33]).

Many policies and programmes to promote digital literacy and ICT use focus on younger people and on schools, which are undeniably important and will lead to improvements in digital inclusion in the coming decades (OECD, 2020[11]). Yet, it is older people who most need and access PHC (Mendes et al., 2019[34]), and more must be done today to include older Brazilians in the digital transformation. Besides strengthening the role of telecentres as providers of training, especially in rural and remote areas, it is important to develop a multi-channel approach to the inclusion of vulnerable groups who are most likely to need and access PHC. Such an approach cannot ignore the crucial role that mobile phones play as a means to access the Internet for older individuals as well as those from rural areas, those on lower incomes, and those with lower levels of education (see Figure 6.4).

Figure 6.4. Mobile phones are the only means to access the Internet for more vulnerable groups

Older, rural, lower income and lower education groups are more likely to use only mobile phones to access Internet

Note: MS = minimum salary.

Source: ICT Households 2019: Survey on the Use of Information and Communication Technologies in Brazilian Households (database), https://cetic.br/en/pesquisa/domicilios/indicadores/ (accessed in March 2021).

Access to mobile broadband is behind the rapid increase in Internet access among the Brazilian population (OECD, 2020[11]). Reliance on mobile connectivity exclusively may prevent some users from accessing more sophisticated services that require higher speeds (e.g. real-time teleconsultations), either because those speeds are not available or data plans are prohibitively expensive. The fact that exclusive use of mobile phones for Internet access is associated with more vulnerable groups could mean that those citizens who most stand to benefit from digital PHC may also be less likely to be able to access it. This is why it is important to adopt a dual strategy of developing new channels to reach these vulnerable groups on mobile platforms, coupled with improvements in high-speed broadband connectivity and digital skills, for example through an expansion of telecentres.

The use of short message service (SMS) and mobile applications to deliver government services is already a reality in many countries, especially in Korea, a country that topped the OECD 2019 Digital Government Index, and where citizens can access government services on their mobile phones. In the United States, the government has set up a mobile first strategy to ensure government services are mobile friendly (United Nations, 2020[35]). In Finland, the government has created a centralised multi-channel one-stop-shop portal that is linked with other specialised portals, thus promoting equity in citizen access to digital government services (ibid).

Adopting a user-driven approach to digital PHC

A user-driven approach describes government actions that allow citizens and businesses to indicate and communicate their own needs and, thereby, drive the design of government policies and public services (OECD, 2020[36]). This requires a shift from a government-centred focus to a user-centred approach that places the needs of users at the core of digital transformation processes and services. A common pitfall of many digital health initiatives is that they fail to adequately engage with health professionals and citizens, leading to products and services that are not relevant to users and add no value (WHO and ITU, 2012[37]).

User needs should be the basis of a digital transformation of PHC. From service design and development through to implementation and monitoring, the user should be present during the entire lifecycle (OECD, 2020[36]). Throughout the process there should be opportunities for feedback and even co-creation. What is key, especially in the Brazilian context, is that a user-driven approach that is accessible and inclusive is also an approach that produces more accessible and inclusive services. Coupled with a strategy to increase digital literacy among citizens, a user-driven approach can engage those citizens that are both most vulnerable and most digitally excluded. Indeed, the now widely used participatory budgeting approach is a Brazilian creation, first implemented in the city of Porto Alegre (OECD, 2019[38]). Participatory budgeting allows citizens a say in how (usually local) budgets are formed and how public moneys are spent. In Porto Alegre, widely seen as a success story, thousands of people have voiced their preferences over the years, affecting how millions of dollars were spent, and importantly – because minorities and vulnerable groups were sometimes overrepresented – shifting public money to where it as most needed (Local Government Association, 2016[39]).

Setting clear well-funded mandates for digitalisation at the right levels of government

A major barrier to digital PHC in Brazil is human and technical capacity in municipalities. Having more than 5 500 municipalities procure ICT products and services for over 42 000 PHC units every five years is not good practice. Around one in five Brazilian municipalities have less than 5 000 inhabitants, and yet they are responsible for hiring ICT specialists and purchasing ICT products and services, from hardware to software, to connectivity and cybersecurity. Often, municipalities either have no providers to choose from, or face prohibitively high costs. As the pilot project in Alagoas has demonstrated, municipal managers lack the capacity to digitalise, even when financing is provided by federal and state governments (Ministério da Saúde, 2020[14]). Setting responsibilities for digitalisation of PHC at municipal level for all of Brazil is likely leading to diseconomies of scale, and creating challenges for small municipalities that do not have the human and technical capacities.

In OECD countries with small subnational government units, such as the Nordic countries, France, the Slovak Republic and Spain, subnational partnerships, joint authorities and outsourcing are frequently used to create scale economies (OECD, 2019[38]). In the context of digital health, specifically, regional health authorities that bring together smaller jurisdictions and provide shared services to all members are a way to achieve both economies of scale and valuable expertise. For example, in New Zealand, primary health organisations or PHOs, especially larger PHOs like ProCare (which serves 800 000 patients in greater Auckland), offer its member practices a centralised human resource, practice management and procurement service (Varsamis, 2019[44]).

Established in 2005, the English NHS Shared Business Services (SBS) provide a mix of finance and accounting, procurement, digital innovation services, employment services, innovation and technology services, and change management to hundreds of NHS organisations (NHS Shared Business Services, 2020[45]). Through a partnership with the Royal Papworth Hospital NHS Foundation Trust, NHS SBS has developed a digital patient booking system that can be rolled out to all NHS organisations (ibid). Also in the United Kingdom, the NHS GP IT Futures programme will create a new environment for the supply of clinical ICT systems to general practice, including a new online NHS Digital Buying Catalogue to find PHC technology systems and services (NHS Digital, 2020[46]). In Portugal, the Shared Services of the Ministry of Health (SPMS) is the Ministry’s central purchasing and ICT authority, providing shared services in the areas of purchasing and logistics, financial services, human resources and ICT. Recently, SPMS added new electronic dynamic purchasing systems for NHS organisations to procure consultancy services in blockchain, artificial intelligence, telemedicine and mHealth from providers that have been certified (SPMS, 2020[47]).

Brazil could look to these examples from New Zealand, England and Portugal for a new model of shared services for digital PHC. Given the geography, population and population density of Brazil, shared services and responsibilities could be aggregated at the level of the federal government, state governments or even health macro-regions and regions, depending on the specific service being considered. For example, dynamic purchasing systems can be set up by the federal government, building on the experiences of the Co-ordenação-Geral de Tecnologia da Informação e Comunicações (CGTIC), which already plans, co-ordinates, supervises and guides ICT investments for the federal government. For smaller states (like Roraima, Amapá and Acre), health macro-regions and bigger health regions could then set up agencies for shared services, providing specialised human resources, purchasing and management services for digital PHC to municipalities.

There are three important policy levers to carry out this regionalisation of competencies for digital PHC:

• First, it is crucial that standards and interoperability remain a central federal responsibility. This does not mean that these should be developed by only the federal government, but it does mean that states and municipalities should participate in this process rather than lead it. This would ensure that whatever systems are procured by states and municipalities, the ability to share data and patient mobility remain possible throughout Brazil.

• Second, these new mandates need to be adequately funded and responsibilities be clearly set. This would guarantee that the new shared services agencies are both able to execute their responsibilities and accountable for the results.

• Third, local leadership, community participation and local ownership remain essential (OECD, 2019[38]). A new model of shared services needs to have the buy-in and ownership of the municipalities and PHC units it is supposed to serve.

Larger and smarter investments are needed to deliver on ambitious digital health strategies

Digitalisation requires investments in infrastructure and connectivity (e.g. high speed broadband), in hardware (e.g. computers), software (e.g. EHR systems), specialised human resources (ICT specialists), user training (e.g. digital literacy of professionals and patients), and importantly, though often neglected, change management and implementation. Brazil has invested significantly in connectivity (e.g. GESAC) and software (e.g. e-SUS AB), as well as providing support for hardware and training (e.g. Informatiza APS). However, as seen in previous sections, substantial numbers of PHC units and teams, as well as citizens, remain disconnected, and thus unable to benefit from a digital transformation of PHC. The vision set out in ESD28 and previous digital health strategies requires both larger and smarter investments, tying financial support to effective and equitable use.

The International Telecommunication Union has recently estimated that connecting every Brazilian to the Internet would cost USD 11.1 billion (ITU, 2020[48]). Brazil’s Connect SUS programme is likely to involve total investments of USD 0.77-1.16 billion (BRL 4-6 billion) over five years (OECD, 2020[11]). In 2019, according to the World Bank Group, Brazil had a population of 211 million and a gross domestic product (GDP) of USD 1.84 trillion. By comparison, in Sweden, a country that in 2019 had just over 10.2 million inhabitants and a GDP of USD 530 billion, the country’s 21 regions invest around USD 1.2 billion annually in health care ICT (U.S. Department of Commerce, 2020[49]). Only 1% of Swedish drug prescriptions are issued in paper format (ibid).

As previously discussed, Brazil instituted an exceptional incentive for municipalities and states digitalise PHC units, budgeting over USD 83.8 million (BRL 432 million) for 2020 (Diário Oficial da União, 2020[50]). In the United States, the FCC’s Emergency Broadband Benefit is a USD 3.2 billion progamme to support households struggling to pay for internet service during the pandemic, providing monthly discounts towards broadband service, as well as one-time discounts to purchase equipment like laptops or tablets, with higher discounts on Tribal lands (FCC, 2021[51]). The FCC’s COVID-19 Telehealth Program provides USD 200 million in immediate support to nonprofit and public eligible health care providers responding to the COVID-19 pandemic by fully funding their telecommunications services, information services, and devices necessary to provide critical connected care services (FCC, 2021[52]).

While it is challenging to compare investments across different geographies, populations and economies, it is helpful to place financial commitments across countries in the contexts of their digital health strategies. The Brazilian ESD28 sets out an ambitious agenda, including milestones for the achievement of certain capabilities (e.g. ePrescribing by December 2022). Looking to the order of magnitude of investments in countries that have already achieved these milestones is a practical way to assess whether current investments are sufficient. As an example, in the United Kingdom, a USD 33.3 million (GBP 26 million) national fund has been set up to have all NHS doctors, nurses and other clinical staff on e-rostering systems by 2021 (GOV.UK, 2021[53]). E-rostering, which allows clinicians to select shifts digitally, providing them with more flexibility and more efficient work schedules, is just one capability.

Investments should also be comprehensive in their scope. It is often the case that one of the most important steps in implementing new technologies – change management and support for implementation – is not appropriately funded (Varsamis, 2019[44]). As the pilot project in Alagoas illustrates, it is possible to have buy-in from municipalities, provide funding, and still have limited adoption. While support in the form of capacity building is undoubtedly important, it might need to be combined with financial support for lost productivity and service disruption during periods of change and adaptation (Bakhai et al., 2019[54]).

It is not just the magnitude of investments that matters. Conditions for accessing these funds by the beneficiaries can promote, or hinder, the adoption and everyday use of digital technologies. Tying financial support to the use of specific functionalities or programmes can be a way to target investments and increase their effectiveness. The Informatiza APS programme already does this by conditioning eligibility for financial support to the reporting of data to the SISAB, but it can potentially go further. The Australian Practice Incentives Program (PIP) eHealth Incentive encourages practices to adopt key digital services, from patient records to secure messaging capabilities (to communicate with both patients and other practices), to ePrescribing, among others (Australian Government, 2016[55]).

Finally, while a digital transformation of PHC has enormous potential (see Box 6.2), there is little high-quality evidence regarding recent digital-first PHC models, such as the one being implemented in the United Kingdom (Rodgers et al., 2019[56]). It is important that funds be made available for continuous monitoring and evaluation of digitalisation in PHC in Brazil.