Accelerating China's Digital Agenda Implementation in Health - Part1

Designing a policy

This is the first part of a policy summary on the Acceleration of China’s Digital Agenda Implementation in Health - another five to follow, to include (1) a detailed meta-policy framework for ecosystem trust policy design and implementation, (2) a few case studies, and (3) an agile governance framework for establishing means and capacity for grassroots innovation and people-centred system change in health.

The motivation for this policy summary came along with China’s digital development and innovation agenda 2021 - 2025 (hereinafter PRC-DA), which was issued three months ago (28 Dec 2021) by the Central Commission for Cybersecurity and Informatization under the 14th Five-Year Plan (1). In this agenda China embraces de-monopolisation and anti-trust policy, distributed identity management on blockchain, the development of an open ecosystem to foster connected and collaborative innovation through data sharing, a development strategy driven by innovation markets, and flexible governance to safeguard an ethical acceleration of digital development for common prosperity.

To this end China emphasises the crucial role of data as a new production factor together with the need to establish and perfect data factor resource systems with data resource exploitation and use, with sharing and circulation, the role of effective digital governance and the need to build up the country’s innovation support capabilities, specifically addressing in the agenda both market innovation and structural or sustaining innovation capacity building.

The acceleration of the PRC-DA thus sets a comprehensive and concise benchmark and paradigm against which to further elaborate on a meta-policy for directionality design and implementation, and on associated toolboxes, specifically addressing: (1) Catalyst-driven and focused digital acceleration, (2) a capitalisation on digital development markets through supporting innovation with an ethical and functioning data ecosystem, (3) governance for connected innovation together with legislative, regulatory and infrastructural facilitation along identified critical challenge quadrants, and (4) expansion of the country’s digital economy share and influence, ultimately strengthening its digital and data diplomacy.

What is now required is an overarching policy and implementation strategy taking into consideration that a key pain-point in innovation ecosystems has been and continues to be the unmet universal need to recycle data by delivering true interoperability within and across governance agencies and their data spaces.

On this note, I hope those brave enough to engage shall enjoy reading this policy summary and very much look forward to your feedback and support to further develop, publish, disseminate and deploy this policy framework in the context of global challenges programmes, toward strengthening Universal Health Coverage (UHC) and promoting the 2018 World Health Assembly resolution on digital health, in the context of the health and health-related UN 2030 Agenda for Sustainable Development, and in the context of the application of a Human Rights Based Approach (HRBA) to the use of technology as the means for promoting equitable, affordable and universal access to health for all, focusing on gender equity and on persons and groups living in vulnerable and marginalized situations - particularly those groups that are vulnerable in the context of digital health and those accessing transitioning health systems under challenging geospatial conditions.

Purpose

This policy summary presents an agile governance approach to the design and implementation of a structure of policy instruments (meta-policy) for the implementation of the PRC-DA, in which approach policy components interact at different levels in order to identify and design preferred development paths on the basis of policy formulated principles, and to govern and steer these paths into set outcomes on the basis of policy-enabled directionality.

Strategic Directions

By means of the PRC-DA, from the perspective of health innovation, China essentially adopts the following strategic directions for digital development:

1. Catalyst-driven and focused digital acceleration;
2. Capitalisation on digital development markets through supporting innovation with an ethical and functioning data ecosystem;
3. Governance for connected innovation together with legislative, regulatory and infrastructural facilitation;
4. Expansion of the country’s digital economy share and influence, ultimately strengthening its digital and data diplomacy.

Priority Actions

Ten directly relevant priority actions for the task of designing health innovation policy are:

1. Digital literacy and inclusive upskilling for the entire population;
2. Enhancing digital development in markets, focusing on data-driven transformations, with the support of digital transformation roadmaps for focus sectors and legislative facilitation for access to data and information;
3. Actions to support advances in frontier and cutting-edge technologies and R&D, including AI, blockchain, and quantum information, systematically exploring digital development opportunities, priorities and demonstrations;
4. Open cooperation in digital trade;
5. Enhancing digital social governance, especially at grassroots, enhancing smart governance capabilities and promoting data resource integration and sharing, including in healthcare and medicine, and in pandemic prevention and control;?
6. Constructing a smart ecological civilization, forging smart and highly efficient ecological and environmental digital governance systems;
7. Actions for rural digital development, including strategies for inclusive digital development and governance, for improving access to data, mobile applications uptake, for entrepreneurship and innovation support;
8. Actions for universal digital financial services and the development of FinTech, including regulatory sandboxing facilitation;
9. Actions for digitization in public health emergencies, and finally
10. Actions to expand smart elder care services.

Policy Identification and Alignment

By contrast to seven years ago (2, 3), the current rate of growth of the digital economy in China favours the adoption of a digital acceleration agenda, particularly so in the health sector (current digital contribution to GDP growth in China is at 40% and climbing - well above the global rate forecast of 25% in 2025). This is true both in the sense that development of the latter may deliver pivotal spillovers (4) to other key sectors of the economy, as well as in the sense that the health sector may provide a solid governance and policy paradigm for open and inclusive digital transformational growth, particularly so on the basis of innovation extroversion and connectivity, and international cooperation, all delivered with new open platform economy models and blockchain.

In fact, in the post-pandemic world, international cooperation, digital foreign policy and cross-border data collaboration will have become global imperatives. China wishes to leverage its high-ranking global position in digital development (5), be an active participant in global digital development initiatives and global data trading development, and influence global governance systems and international trends, gaining global competitiveness with support to domestic entrepreneurial efforts to platform grassroots innovation and by providing access to an organised and regulated ecosystem that supports sustainable transformational growth through the adoption of circular economy models - thus also enabling and supporting the effective participation of smaller players in the digital economy by means of special provisions and policies designed to mitigate market entry barriers such as access to data or access to regulatory sandboxes. This model is to uphold the basic points of the PRC-DA underlying strategy to expand internal demand, fully express the crucial role of data as a new production factor, to establish and perfect data factor resource systems with data resource exploitation and use, with sharing, and circulation; with whole-lifecycle governance and security protection as focus points, activate the factor value of data, enhance the role of data as a factor endowment, shape a strong domestic market that is innovation-driven, high-quality, supply-led, and creates new demand, and promote the building of new development structures for the economy.

The aim is to facilitate domestic and international market entry, to accelerate growth with connected innovation and recycling, skyrocket invested capital efficiencies and reduce the carbon footprint of the digitalisation process, leading to a non-excludable digital economy development process (6).

All of these principles are essential ingredients of any modern health innovation ecosystem strategy, central to the modernisation of grassroots social governance systems, and are systematically supported in the PRC-DA. What is now required is an overarching policy and implementation strategy - one which takes into consideration that a key pain point in innovation ecosystems has been and continues to be the unmet universal need to recycle data by delivering true interoperability within and across governance agencies and their data spaces (7). Thus, on the basis of the projection of the PRC-DA in the health sector, an overarching policy that serves its goals would be to deliver data solidarity through social governance and innovation in health, promoting and safeguarding trusted data sharing.

In order to reach this composite goal, and to maintain directionality in what is to be a complex and heavily matrixed environment for the pursuit of this PRC-DA in health, an implementation strategy specific to health is to identify and implement within specific, prioritised, high-impact intervention areas, projects and tasks that promote the agenda and the overarching policy, in a systemic, agile and risk-mitigated, collaborative, standards-driven manner, in line with a set of adopted policy components and governance frameworks and underpinned by the core digital policy tenet to deliver an open, decentralised and inclusive digital development enabling innovation ecosystem.

Going forward, as increasingly wider and more complex challenges are to be addressed by transition-oriented digital development agendas and corresponding delivery policies, the higher the likelihood shall be of failure to identify and reach consensus on a portfolio of acceptable development paths, and thus the higher the risk of a lack of directionality and of directionality failure (8). Moreover, as a large number of heavily matrixed factors, actors, perspectives, innovations and impacts are mission critical toward the translation of a digital transformation agenda into directions, the methodologies underpinning successful policies and overall approaches to trust-by-design in interventions, must ensure (1) the alignment of key system-wide challenges with policy components - for instance a technology policy that delivers on the challenge of national and global chains-of-custody underwriting the evidence for public health systems reform and policy, together with (2) the layering of these policies and their weaving together by means of (3) an additional agile governance layer. This meta-policy structure (Figure-1) shall also constitute the core strategy delivery mechanism for sustainable development going forward: a regulatory framework for setting, measuring and safeguarding directionality in the designed and adopted policy instruments.

Policy Instruments

Specific policy instruments are identified for each strategic direction and aligned with the agenda as follows:

1. Establish the means, organisational structure and operations to identify, focus on and support priority digital health intervention (DHI) areas which best catalyse digital acceleration;
2. Support the pursued DHIs with a focused development of a data ecosystem that safeguards innovation sustainability and interoperability, data recycling and solidarity, and ethical digital transformation;
3. Develop and deploy policy instruments which enable and support connected innovation, including at the levels of technological, legislative, regulatory, infrastructural, data and social governance policy, with emphasis on how these affect the ecosystem (environment), the pursued DHI-driven transformations (outcome) and the deployment models for digital health services (performance);
4. Scale the DHIs to strengthen China's digital foreign policy and data diplomacy.

Fig-1. Meta-policy structure

Policy Structure

Policy instruments are aligned against the following four PRC-DA spanning implementation strategy priorities.

A. Catalysed and focused digital acceleration

• Adopt and implement an agile innovation and ecosystem governance approach to catalyse and focus digital acceleration in health (see Part-4) engaging stakeholders across the board to design transformation and transition interventions and policies, adopting a portfolio approach to system change.
• Establish horizon scanning capacity and operations at the levels of policy, system and organisational arrangements, building on the existing public health services delivery structure, in order to systematically explore and pursue digital development opportunities, priorities and demonstrations, while identifying and prioritising specific prevention and therapy areas. An alternative model is presented in the recently published UNDP guide to the adoption of a portfolio approach designed with rapid ethnographic research to implement system change, as a methodology for understanding and addressing complex development (and thus policy) challenges, with particular focus on analysing and synthesising into change process different challenge components and perspectives by individual stakeholders, drawing a parallel to methodologies such as horizon scanning and the use in agile governance (9).
• Identify costs - such as data resource use requirements, and the range of health, health-related and non-health effects (utilising an impact inventory approach) and comparators to be included in economic evaluations (for cost-effectiveness analysis) relating to the purpose of specific DHI areas (10). The evaluation shall factor in all the costs associated with transformation and transition in accordance with the adopted policy components and the designed development paths (see outline parts below).
• Pursue the identified and prioritised prevention and therapy focus areas on the basis of spot evaluations results.
• Implement the PRC-DA and apply the policy instruments defined, along the designed development paths and within each prioritised focus area, circling around with lessons learned to improve instruments and the ecosystem.
• Prioritise prevention and therapy areas which catalyse digital transformation acceleration and provide solid transition directionality, for instance genomics and precision medicine or translational research.

B. Sustainable capitalisation on digital development markets through supporting innovation with an ethical and functioning data ecosystem

• Formulate, adopt and develop a smart grassroots social governance (GSG) for data solidarity framework, including the adoption of necessary interoperability governance models and principles, technology standards, and best practices, including but not limited to the adoption of new enabling patient-centred care services and procurement models, and key technology policies, such as, distributed identity management on Blockchain, safeguarding collective data provenance and immutability, and interoperability models for hybrid database solutions involving digital ledgers and the cloud. A smart GSG framework should incorporate both the means and the technologies which enable grassroots change and empower community participation.
• Develop and adopt a national overarching trust-by-design policy framework to enable and regulate data resource integration and sharing, including how to apply and audit the principles of accuracy, reliability, data and information interpretability, accountability, privacy, equity, value, transparency, security, non-maleficence, and so on, as enablers and safeguards to create trust in the data economy and drive adoption and engagement, thus inclusive digital development. An expanded set of principles which are to steer the transformation direction along the designed development paths is provided in Part-3.
• Deploy the above to develop and scale: (1) Telehealth and telecare models and services, (2) Distributed digital identity and digital fingerprinting infrastructure, (3) Patient data wallets, (4) Digital clinics (scope defined and evaluated as above) within digital or internet hospitals (11), (5) Data connectivity and interoperability services, including mobile applications and an m-Health suite of access and engagement tools.

C. Governance for connected innovation together with legislative, regulatory and infrastructural facilitation

• Develop and deploy connected innovation enablement and support instruments, including legislative, regulatory and infrastructural facilitation: including but not limited to, the regulation and policy on secondary uses of data, on privacy protection, on digital identity and trusted services, patient data wallet standards and interoperability standards, and a comprehensive data integration roadmap and regulatory framework.
• Develop digital transformation roadmaps for the prioritised focus areas and designed development paths – emphasise standardisation, spillovers, resource reuse and connected innovation.?

D. Expansion of the country’s digital economy share and influence, ultimately strengthening its digital foreign policy and data diplomacy

• Scale governance models and digital agency on the grounds of the exploration of concepts such as the digital assets fiduciary, data asset stewards (12), data trusts, the data collaborative, cooperative or data commons (13).
• Extend regulatory approaches, governance models, frameworks and various instruments as above, such as cybersecurity law, to enable and cover cross-border data flows, to include open, limited and conditional data transfer models.
• Establishment of digital diplomacy and participation in international fora to promote China’s candidacy as a global centre for health data governance (14).

Synthetic policies and policy fabrics

The approach and method adopted toward this meta-policy, or policy design and implementation framework, consists of policy layering and weaving in order to align different design aspects and to maintain meaningful coordination. More specifically, policies are synthesised and adopted to deliver DHIs at the levels of value, equity, and trust, as well as at sub-layers and sub-components. Furthermore, to ensure directionality is maintained throughout project life-cycles and through the transformation and transition process for stakeholders, institutions, and regulatory frameworks, the cross-cutting layers of technology and infrastructure policies and a third policy dimension of governance, the later with its own sub-components, are weaved into the former structure elements forming a design fabric which can be instantiated into implementations as DHIs.

To illustrate the above, a trust governance policy shall define both (1) the existence layer for the Self-Sovereign Identity implementation for users - in the form of an identity fabric that runs through both on-chain and off-chain knowledge and data graphs (technology policy components), as well as (2) the consensus model and protocol developed to deliver an ultimate performance for the chain-of-trust design (governance component). Each of these considerations shall be reflected in corresponding value and equity policy components. Each layer thus provides guidance and directionality with regard to a group of design features and impacts those at other levels during the weaving and alignment process.

As wider more complex challenges are addressed in transition-oriented digital development agendas and delivery policies, the risk of failure to identify and reach consensus on a portfolio of acceptable development paths increases, hence risk of a lack of directionality, and thus directionality failure. As a large number of heavily matrixed factors, actors, perspectives, innovations and impacts are mission critical toward the translation of a transformation agenda into directions, the methodology adopted in this policy note in the approach to trust-by-design in interventions, is the alignment of key system challenges with policy components -- for instance a technology policy that delivers on the challenge of national and global chains-of-custody underwriting the evidence for public health systems reform and policy, together with the layering of these policies and their weaving together into policy fabrics by means of additional agile governance layers.

In further detail, high-level policy components in this summary are set out as follows:?

1. An overarching trust-by-design policy to underpin digital development and PRC-DA implementation in health, following and expanding on the paradigms of privacy-by-design and ethics-by-design, to establish a trustworthy innovation ecosystem and thus trustworthy data sharing and health innovation;
2. Sustainable development of China’s trusted innovation ecosystem, focusing on data recycling based and connected innovation;
3. Develop and adopt an agile governance framework to maintain directionality in policy design and implementation, to manage complexity and risk, to accordingly weave policy layers into a matrixed regulatory environment that supports sustainable trusted ecosystem development, to maintain a feasible and strategic pace and scale at all times, as well as for the regulation of the delivery process;
4. Develop aligned telecare models and services while pursuing an ecosystem capacity and systematic infrastructure scaling along critical challenge quadrants and in line with the adopted policy guidance.

Essentially the proposed policy guidance for the development of China’s digital health ecosystem aims to provide for platforming the implementation of the PRC-DA in health, building on and leveraging China’s expanding presence in the areas of telemedicine and internet hospitals and their governance (15), together with a custom trust-by-design policy for data and services, which aims to shape and guide the agile and evolutionary implementation of China’s health innovation vision as set out in the PRC-DA and this policy note. That is to embrace AI and foster non-excludable and open, connected innovation and common prosperity, in order to drive change at the grassroots and government, at the policy and health system reform crossroads, and toward new models of care, economics and public service interaction.

Each policy component as described above, shall comprise a number of sub-components which further provide for trust design directionality and focused, normative, formative and transformative innovation. The set of adopted trust-by-design policy sub-components, such as accuracy, reliability, data and information interpretability, accountability, privacy, equity, value, transparency, security, non-maleficence, and so on, are enablers and safeguards that create trust in the data economy and drive adoption and engagement, thus inclusive development, also in accordance with the social contract for data of the World Bank Flagship Report “Data for Better Lives” (2021) and the proposed model of Value, Equity, and Trust (Figure-2).

Fig-2. Social contract for data founded on value, trust and equity (15)

Furthermore, the proposed ecosystem-oriented strategy, approach and policy guidance are driven by the system-level challenge to deliver transformative innovation toward a people and community-centred, value-based care and precision public health system, focusing on addressing issues of data ethics and sustainable innovation, and on deploying new technologies and open platforms to build collective data agencies and chains-of-trust. The goal is to piece together the expanding national and global space of data, to leverage and facilitate digital foreign policy and diplomacy (16) and to enable a circular digital economy of connected innovation and seamless collaboration - one which enables reliable reuse and eliminates waste and complexity (17).

China’s healthcare organization and service delivery model reform programme toward people-centred integrated care (PCIC) (18), also adopted in the Healthy China 2030 strategy, provides a fitting innovation scaling environment. This digital agenda implementation policy aims to exploit and leverage this advantage by focusing on specific problem domains and mobilizing local communities around those. Furthermore, the proposed approach is in line with China’s major paradigm shifts in the PRC-DA, to include:

1. Anticipatory (active) regulatory interventions;
2. Inclusive growth and common prosperity (destiny), and coevolution;
3. New infrastructure development fusing together hard and soft technologies and innovation, including the new internet, devices and connectivity, disruptive and sustaining innovation, and
4. Shift from a paradigm of generic digital development strategy to a paradigm of focused and regulated data (-driven) development.

On the side of technology policy, the key policy components that underpin the PRC-DA strategic priorities in health, specifically and in alignment with the proposed sustainable digital development policy, are the following:

1. Telehealth services and virtual care channels, backed by
2. Patient data wallets (19, 20, 21, 22, 23, 24), together with?
3. Digital health ledgers on blockchain.

Together these technology policies shall focus the deployment of resources on the equitable and inclusive transformation of the health sector to pace and scale, mobilising and leveraging the wider engagement and participation of the community. This strategic approach is to be furthermore enabled by new care and virtual care models built on mobile application platforms, the telehealth infrastructure and wearable devices, thus setting a paradigm shift for other public services sectors to follow (25). Genomic and precision medicine models of care and treatment, including precision prevention, are an example of such.

Blockchain technology with smart contracts as means to deliver the necessary requirements for new procurement models, for self-sovereign identity management, immutability, provenance, and thus citizen-driven collective data agency are proposed together with cloud-data-level clinical interoperability models, mobile health and Internet of Things (IoT) integration, to platform the inclusive participation of patients and citizens as partners in the transformational growth process, with mobile and tele-health as access and engagement channels.

Overall, the proposed technology policy is in alignment with the PRC-DA and particularly fitting for the conditions of growth in China, and in other parts of the world with similar geospatial characteristics, as the current observed low rate of 63% coverage with online banking in rural areas is countered by an almost exponential growth in internet data consumption over the past few years.

--

Part two of the policy summary introduces the different layers for interactive policy design and implementation, their interaction within and across critical challenge quadrants, as well as different governance layer perspectives and instruments.