There is increasing recognition that digital health solutions can strengthen health systems by expanding coverage of healthcare, enhancing safety and quality of services, and optimising resources to make services affordable for underserved populations (1, 2). The last decade has seen the proliferation of digital health interventions, defined as the use of information and communications technology in support of health and health-related fields. Despite increasing global investment in and sophistication of digital health solutions, reports from low- and middle-income countries (LIMCs) have been skewed towards short-term (12–24 months) pilot interventions, feasibility and acceptability studies (3). There remains uncertainty in the long-term sustainability of most digital health solutions (4). This suggests that the chances of achieving long-term benefits of digital health, such as universal health coverage and health-related Sustainable Development Goals by 2030, remain slim, as most pilot innovations are seldom brought to scale.

Existing literature is beginning to explore and determine multiple factors that can act as both enablers and barriers to scale-up at the micro (e.g., end user characteristics, social support), meso (e.g., regional infrastructure, culture) and macro (e.g., regulation, funding, reimbursement) levels (5). This is happening alongside the identification of areas that require consideration for scale-up, including program characteristics, human factors, technical factors, healthcare ecosystem, and the extrinsic ecosystem (6). But there remains a need for evidence to inform strategies, frameworks and models that can guide scale-up of digital technologies for diverse use cases including, for example, across reproductive, maternal and child healthcare, infectious diseases, chronic care, emergency preparedness and response, and health system integration and interoperability, particularly in low-resource settings.

In recent years, particularly in the context of low-resource settings, the COVID-19 pandemic has triggered escalated development and use of digital health tools and restructuring of the health ecosystem (7). With increasing innovation and digital health solution development, it is critical to develop and expand the evidence base to guide scale-up and sustainability and explore opportunities for its consideration from the earliest stages of intervention design through to large-scale testing and evaluation.

This Research Topic presents multidisciplinary papers that explore and document evidence identifying contextual factors influencing the scale-up and sustainability of digital health solutions, and theoretical or practical strategies for overcoming barriers to scale-up.

In total, eight (8) papers were included in the collection, providing findings from studies conducted across countries in Africa (i.e., Nigeria, Rwanda, Sierra Leone and South Africa). Included papers encompassed a wide range of topic areas including management of COVID-19, sexual and reproductive health and maternal healthcare, specific technology approaches such as the role of artificial intelligence and machine learning, and broader applications of digital technology for health insurance, human resources strengthening, patient identification techniques, tackling misinformation and disinformation, and enhancing universal health coverage.

Across the collection, scale-up has been defined as the embedding of a digital health product into each level of the health system (policy, practices, workflows, and daily lives of health workers) to improve output (access, scope, quality, efficiency), outcome (coverage, utilization) or impact (morbidity or mortality) rather than regrading digital interventions as standalone initiatives. Sustainability is defined as the longevity and continuing manifestation of benefits and outcomes of digital solutions on the health workforce, standard of healthcare, patient experience, and the environment long after the initial phases of implementation of the technology.

The focus on scale-up and sustainability varied from studies that were horizon scanning and considering scale-up during the early stages of intervention development, alongside articles outlining interventions that have been scaled up nationally and reflect on the process and longer-term sustainability, alongside a systematic review of barriers and facilitators for sustainability.

The evidence we present within this collection is multifaceted, encompassing diverse research types and providing multiple first-hand accounts of differing levels of implementation, drawing out key factors to consider in planning for and assessing their potential for scale-up and sustainability. Across the articles included in this collection, there is evidence of multiple best practices around scaling digital health, including designing with the end user, building for scale and sustainability, addressing privacy, and being collaborative (6). Broadly across digital health, there is more evidence required to guide the implementation and evaluation of solutions to inform decisions around scale-up and move towards universal coverage (8).

The COVID-19 pandemic undoubtedly heightened the importance of digital health technologies and their application as part of care delivery, providing routes to guaranteeing access to services for millions who could not obtain in-person care. Whilst digital health provides the potential to remove barriers to health care and tackle established global health inequities for vulnerable groups, a global post-pandemic vision for digital health remains unclear, with a need for country and context-specific adaptation of approaches to its use (9). Multiple, established approaches to user involvement can be utilised to support the design and adaptation of digital health interventions for specific contexts (10). This is supported by examples of approaches that map and determine user preferences and needs for digital technologies applied to specific disease groups across multiple stakeholder groups to guide subsequent technology development (11).

A critical area moving forward is the need for greater understanding around digital health equity, ensuring conscious design of approaches to ensure they meet the needs of the most deprived, to avoid exclusion (12, 13). Work by Okuzu et al. provides evidence that digital technology can be used to increase access to, for example, health insurance in vulnerable populations where requisite enablers are in place (e.g., key stakeholder engagement and a supportive policy environment to which the intervention aims are aligned). However, Udenigwe et al. highlight remaining challenges around gender and cultural inequalities in digital health. Two areas of critical questioning remain if digital health is to evolve to produce scalable and sustainable tools to support universal health coverage. First, how can scaling digital health interventions promote equity and inclusion? The World Health Organization (14) recently recognised health equity as one of four cardinal principles of its Global Strategy on Digital Health (2020–2025), requiring investment in infrastructure, education, and resources to help LMICs adopt and scale novel digital health interventions. Second, what difference has the global rapid increase in the application of digital health approaches during and after COVID made in the lives of patients? Has it had an impact on universal health coverage as part of SDG-3, and to what extent has it closed the health inequity gap for different groups (youths, elderly patients, mental health patients)?