Participants pointed to significant momentum in the adoption of foundational digital public infrastructure (DPI) across low- and middle-income countries, with digital identity systems, payment rails, and data exchange platforms increasingly in place. The health sector has both benefitted from and contributed to this progress. Yet it was equally clear the potential of DPI for health remains far from fully realised. Notably, the health sector has accumulated considerable experience related to pursuing the goals of investment into common digital infrastructure, which will need to inform strategies for DPIs for Health. Implementation has too often followed narrow programme priorities driven by individual donors rather than national health system goals. This has resulted in fragmented digital landscapes in which patient identity systems, longitudinal records, and metadata registries have been designed and built in isolation.
Several trends emerged as particularly significant. For foundational DPIs, the growing involvement of development banks was noted as an important shift, creating both significant opportunity and risk. Opportunity comes from the potentially transformative scale of investment, yet without the right governance and technical conditions in place, this risks locking in the very fragmentation the field is trying to overcome. Participants also noted the persistence of vendor-driven solutions that create “walled gardens” – i.e. proprietary systems that undermine long-term interoperability and transfer costs to governments. The economics of infrastructure investment, as one participant put it, “basically sucks”, and without a dominant use case and a credible value narrative, political and financial buy-in remains elusive.
There was broad agreement that a fundamental shift is needed, one that sees DPI not as a collection of technology projects but as an enabler of public services provided by governments, delivering the standards-based capabilities needed to de-risk private sector solution development, and enable citizens to use those solutions effectively. This reframing has practical implications for how DPI is designed, procured, financed, and governed. It also changes the nature of the value proposition: rather than leading with technical specifications, advocates for DPI in health must articulate what it means for end users and beneficiaries, such as reduced waiting times, on-time payments and detection of fraud in supply chains. In this framing, a central role of government is to define and steward the specifications, standards, and architectural guardrails needed to ensure that investments contribute to a coherent DPI-based architecture that delivers value across all constituencies for health sector goals. There was an acknowledged role for health sector-specific DPIs (health records, metadata registries, etc) and cross-sector DPIs (ID, payments systems, etc) each necessary for sustainable digital transformation of the health sector.
“Sustainability by design” was a recurring theme throughout the dialogue, positioned as a central principle for designing DPI for health. Five dimensions were outlined:
- Value proposition – the stories that articulate the real-life benefits, for governments, donors, and citizens (e.g. framed around ‘DPI as a service’)
- Technical architecture and standards – the pathways and foresight needed to move beyond silos and enable modular, interoperable capabilities that support multiple health sector goals and unlock the full potential of DPI for health.
- Organisational structures – the ways of working that overcome fragmentation, provide dedicated institutional homes, and realise the benefits of working across sectors.
- Financial resilience – the financing approaches and investment strategies needed to ensure DPI for health can be maintained, governed, and evolved over the long term with local resources.
- Legislation – the foundation that establishes trust and accountability and provide a basis for long term sustainability.
Country perspectives
Several countries shared their experience directly, offering grounded insights into what works, what does not, and the conditions needed to make a difference.
- Sri Lanka demonstrated the value of investing in internal capacity building alongside digital infrastructure. The Postgraduate Institute of Medicine, under the leadership of the Ministry of Health, has created master’s and doctoral programmes for medical professionals to build digital health technical literacy within this cadre. An “experience centre” was developed to help the public understand what they could expect from DPI-enabled services in practice in the future. Despite these advances, Sri Lanka has found it difficult to scale existing open-source solutions across its population of 22 million without additional external support.
- Bhutan established a central GovTech Agency as part of a whole-of-government digital reform, consolidating ICT resources across ministries. This has reduced duplication and enabled the development of a single, interoperable national data exchange backbone. While consolidation has strengthened national infrastructure, it has also created institutional challenges at the sector level, particularly due to the absence of a dedicated governance and technical anchor for digital health within the Ministry of Health. The experience has demonstrated that high-level political commitment alone is insufficient; effective digital public infrastructure requires sector-level institutions with day-to-day operational authority working alongside political leadership. Sustainable DPI depends not only on platforms, but on robust governance structures and skilled technical teams.
- Zambia presented a model with a governance body anchored in the Office of the President and created through an Act of Parliament. The independent entity has authority above individual sector ministries, a digital health working group (which is part of the Ministry of Health, and includes representation of Smart Zambia, the eGovernment division which sits under the Office of the President) spans multiple sectors, and has the technical capacity to advise political leadership on sound decision-making. Critically, no digital decisions can be taken without the involvement of this entity. The country is developing guidance on upskilling teams in enterprise architecture and is engaging universities as part of this effort.
- From Latin America and the Caribbean the Pan American Highway for Digital Health (PH4H) – a partnership between PAHO, the IDB, and countries of the region – was presented as a regional model for aligning and accelerating investments. The initiative, approved by all countries of the Americas in the PAHO 61st Directing Council, frames digital health in terms of “traffic rules” (governance), “cars and drivers” (users and use cases), and “road-paving” (technical standards and digital infrastructure). PH4H also holds ‘Connectathon’ events, bringing together over 17 countries (with incentives such as innovation awards) to exchange data and drive collaboration between technical teams across borders. Through this work, the Americas has become the first region in the world to issue Digital Yellow Fever Vaccine Certificates using the WHO Global Digital Health Certification Network. The IDB expressed openness to expanding participation in their connect-a-thons to other countries outside of the LAC region.
Across these country and regional perspectives, common themes emerged: the importance of institutions that outlast political cycles, the value of peer-to-peer learning and regional collaboration, the need for dedicated technical capacity rather than reliance on external consultants, and the central role of clear mandates backed by legislation.