Governance emerged as the most consistently cited constraint on sustainable digital public infrastructure (DPI) for health, and breakout groups on this theme generated concrete analysis and recommendations.
Participants were candid about why silos persist: incentives in most systems reward vertical programme solutions rather than shared infrastructure. Career trajectories, procurement systems, and funding structures all create conditions in which departments are better rewarded for protecting their own systems than collaborating across boundaries. Coordination is, above all, a political economy problem, not a technical one.
While health sector-specific DPIs must be governed by the health sector, cross-sectoral DPIs require governance at a level above individual ministries. In practice, this often means anchoring authority in the President’s or Prime Minister’s office; not because health or finance ministers lack interest, but because only that level of political seniority can enforce coordination across sectors. While high-level political leadership is essential, alone it is not sufficient. It must be backed by empowered technical institutions such as secretariats, e-government/technology ministries, digital health agencies, or equivalent bodies, that each have clear mandates, adequate resources, and day-to-day operational authority. Agencies managing cross-sectoral DPI should embrace a service delivery mindset, engaging sectoral ministries (including health) early in planning and design to understand sector needs and use cases.
Groups explored the governance failures that most consistently undermine sustainability: the absence of clear accountability and decision rights; the lack of coordination mechanisms between health, finance, and technology ministries; and the failure to design for institutional and financial sustainability from the outset of a programme.
The suggestion for the development of a clear RACI (Responsible, Accountable, Consulted, Informed)-type framework to govern cross-sectoral DPI programmes emerged from the discussion. Establishing which parts of government, and non-government are responsible for governing health sector content, who has ultimate accountability for the technology implementation, and ensuring the DPIs address health sectoral capability requirements, who needs to pay, and who needs to be kept informed (across health, finance, and digital government functions) was identified as one of the more practical and immediately actionable governance frameworks that needs to be developed for governments and their partners.
Participants emphasised the critical value of simplifying the language used to communicate about DPI to political decision-makers. One suggestion was to focus around three core things: reduce the burden of data collection on health workers, improve the quality of provider and patient interactions, and improve health outcomes. The need to provide evidence of cost-savings and efficiencies was also mentioned by participants. Politicians respond to narratives grounded in the concerns of their constituents and the realities of their political cycles, and DPI advocates must meet them there.