PART 2 |
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Authors: Nelson Ekane, Somya Joshi, Henrik Carlsen and Nina Weitz, Stockholm Environment Institute |
Sustainability in digital health care:
A new tool for evaluating impacts
The aim of this part is to broaden the perspective on the potential impacts of digitalisation in the Nordic welfare sector, from a narrow focus on climate impacts and carbon footprints to a broader focus that includes social, economic and other environmental dimensions.
A broadened scope reflects the 17 Sustainable Development Goals (SDGs) and the United Nation’s 2030 Agenda. These interconnected goals address the global challenges we face, including those challenges related to poverty, inequality, climate change, environmental degradation, peace and justice. The target is to achieve the SDGs by 2030. They are applicable to all countries and integrate social, environmental and economic aspects in a globally agreed vision for a sustainable world.
This is also in line with the Nordic Council of Ministers’ Vision 2030 of the Nordic region becoming the most sustainable and integrated region in the world by 2030.
Introduction: Digitalisation of the welfare sector and the potential impacts of sustainability
What kind of sustainability impacts could result from the digitalisation of the health and welfare sector in the Nordics? The Nordic countries make wide use of digital technologies for communication and the delivery of their respective welfare services. The public sectors are among the world’s most digitalised.
The vision of the Nordic region comprises three strategic priorities: a green Nordic region, a competitive Nordic region and a socially sustainable Nordic region. Digitalisation has the potential to contribute to all three aforementioned priority areas. However, the widespread use of digital technologies also presents challenges such as inequality in accessing digital services and the environmental footprints of digital transformation. This is resulting in inequality in terms of who actually benefits from the digitalisation of public services. Inequality is known to erode trust in public authorities and is a danger to healthy democracies. The environmental footprint of such a digital transformation is considerable.
In this respect, in its last report, the Intergovernmental Panel on Climate Change (Working Group III, which focuses on climate change mitigation) states: “At present, the understanding of both the direct and indirect impacts of digitalisation on energy use, carbon emissions and potential mitigation [of carbon emissions] is limited.”
In 2019 the UN’s Special Rapporteur on Human Rights called for attention on the widening gap between the rich and poor as a result of digitalisation.
Digitalisation is widely recognised as a megatrend shaping economy and society and, as a general purpose technology, has impacts across economic sectors and society through automation, digital platforms, AI and cloud computing.
While the literature primarily focuses on the impacts of digital applications (Horner et al., 2016), as seen through the lens of direct and indirect energy and material footprints, relatively less attention is given to the systemic impacts on society, i.e. in terms of social impacts, for example, norms, social trust, misinformation, the digital divide, social inequality, infrastructure access, and economic impacts, for example, jobs, income inequality, trade, productivity, skills, competitiveness. The way in which digitalisation is used to manage or mitigate these impacts is also important (e.g. how policy or regulation should tackle the dynamics of market power, the digital divide and the intended and unintended consequences of AI) (Creutzig et al., 2022).
The Nordic countries have the technological readiness to support the digital transformation in the welfare sector but this also emphasises the urgent need for key stakeholders to prioritise and identify areas of engagement and develop robust action plans. From a sustainability perspective, the areas of engagement and action plans should reflect the various dimensions of the SDGs. The purpose of this chapter is to enhance the understanding of the potential implications of digitalised health care on the different dimensions of the SDGs. This has been conducted in the project - Integrated Healthcare and Care through Distance spanning solutions (iHAC).
To address the above concerns, this chapter examines the digitalisation of health care in the Nordic countries through the lens of the SDGs in model projects in different regions in the Nordic countries – the Agder region in Norway; the Päijät-Häme wellbeing services county in Finland; Fjallabyggd municipality in Iceland; and Tiohundra in Norrtälje, Sweden. To ensure a scope that is broader than the impacts of climate change alone, we rely on the UN’s 17 Sustainable Development Goals (SDGs).
Photo 2. The 17 Sustainable Development Goals.
The objectives of the iHAC project are as follows:
- Gather stakeholders’ perceptions of the sustainability of digital healthcare solutions within their various contexts, and identify opportunities and challenges for introducing digital healthcare and care solutions.
- Introduce a methodology (“SDG Synergies”- see Box 1) to systematically explore the sustainability implications of digital healthcare solutions
- Explore and map the interactions between a range of digital healthcare and care solutions and a range of social, economic and environmental goals as defined by the Sustainable Development Goals (SDGs).
- Initiate learning and knowledge sharing between the projects with reference to the 2030 Agenda and the SDGs.
These objectives have been achieved via two activities: first, multi-stakeholder workshops were organised in the model regions to consult stakeholders and mobilise them to participate in the SDG Synergies workshop. This addressed the first objective; the multi-stakeholder workshops were followed by an SDG Synergies workshop that addressed the remaining objectives.
In the following, the process and outcomes of a participatory exercise to systematically explore the socio-economic and environmental impact of distance spanning solutions in health care are described.
The Nordic project Integrated Healthcare and Care through distance spanning solutions (iHAC)
Integrated health care and care with the citizen’s perspective in focus is gaining ground in all Nordic countries. Health care and care are offered in people’s homes based on their own needs. However, there are challenges in coordinating the service providers due to silo mentality and different areas of responsibility. Digitalisation and remote services are important prerequisites for maintaining the quality of the Nordic welfare model. In addition, digital service models are a necessary first step to creating efficient integrated health care and care. The iHAC project is part of the Nordic Vision 2030’s action plan and aims to contribute to the Nordic Council of Ministers’ goal of making the Nordic region the most sustainable and integrated region in the world by 2030. However, from a sustainability point of view, it is important to take into account different perspectives.
As the three pillars of the Nordic Vision place emphasis on a green, competitive and socially sustainable society, the 12 indicators that form part of these pillars provide a granular understanding of what this actually means. In this report we refer to the indicators relating to digitalisation, equity and health as part of a green and socially sustainable Nordic region.
Four Nordic model regions
The model regions included in the iHAC project comprise ongoing and planned distance spanning solutions in four Nordic countries – the Agder region in Norway, Päijät-Häme wellbeing services county in Finland, Fjallabyggd municipality in Iceland and Tiohundra Norrtälje in Sweden. These model regions aim to achieve the provision of integrated healthcare and care services supported by distance spanning solutions.
Since 2013, several telemedicine monitoring services have been introduced in the region of Agder with the aim of creating a common technology platform to facilitate procurement, operation and support. These services have been implemented in close collaboration with the Hospital of Southern Norway. The aim is to provide access to a simple and secure comprehensive digital health and care services for all citizens in the Agder region. This is presented in the report Integrated Healthcare and Care through distance spanning solutions – for increased service accessibility.
The home care services for the elderly in the Päijät-Häme region are based on a centralised and inclusive model in which patients are regarded as clients. The innovations in home care services in the region were undertaken in response to challenges linked to limited nursing resources, decreased well-being of health professionals, and the increasing cost of health care and care.
The TioHundra Norrtälje model in Sweden integrates county-operated health care and municipality-operated social care services. This involves a collaboration between Norrtälje municipality, Region Stockholm and Tiohundra AB. The TioHundra collaboration has been running since 2006 with the aim of providing access to health care and care services for all. The TioHundra model consists of an integrated approach to ensure high quality care for patients.
The Fjallabyggð municipality in Iceland is planning to integrate health and social care services. This is a collaboration between the municipality and the state to support the elderly population and provide citizens with a holistic view of their health and well-being.
The SDG Synergies approach: a methodology to explore the socio-economic and environmental impact of distance spanning solutions in health care
In 2015, the UN member states agreed on an ambitious global agenda for sustainable development: the 2030 Agenda. For the first time, a global development agenda was adopted that integrates social, economic and environmental dimensions. The 2030 Agenda states this in an overarching declaration, 17 Sustainable Development Goals (SDGs) with 169 targets and an indicator framework.
This new approach raised the bar for integrated planning and policy coherence, as many of the goals are interlinked. It is often the case that progress on one of the SDGs makes it easier to achieve other SDGs, although this is not always the case and there are some difficult trade-offs which, if left unmanaged, can slow down or even undo progress. Halfway into the implementation period (which runs between 2015 and 2030) the 2030 Agenda also seems to be influencing how policymakers think and communicate about sustainability; it is broadening their view and understanding of the interactions between social, economic and environmental goals.
With the SDGs, demand grew for scientific methods and practical tools that could help decision-makers to navigate the ways in which the various goals interact, as well as how other goals or agendas interact with the SDGs. Such tools could help to avoid the unintended effects (trade-offs) on other policy areas by planned actions, and capture the co-benefits (synergies), thereby using resources more efficiently and ensuring that the outcomes are equitable.
The SDG Synergies tool, developed by researchers at the Stockholm Environment Institute, is one such tool and has been chosen for the participatory exercise described here. See box 1 for an overview.
Box 1. The SDG Synergies approach and tool.
The SDG Synergies approach and tool – what is it?SDG Synergies is a practical tool for exploring how goals or policy areas interact. It was originally designed to support governments in implementing the Sustainable Development Goals but will help any user to record, visualise and analyse how multiple targets are likely to interact in a given context. It combines a participatory process in which stakeholders assess interactions in a structured way, as well as network analysis to reveal deeper patterns and relationships between goals that would otherwise not have been observed by merely looking at the interactions between targets in a pairwise manner. In a participatory, discussion-based scoring process, SDG Synergies users develop a cross-impact matrix of interactions based on a simple question: “how does progress on goal x influence progress on goal y?” (repeated for all matrix elements). The completed matrix immediately gives an overview of the direct synergies and trade-offs and, using intuitive controls, it is then possible to explore different aspects of the system. Using advanced network analysis and visualisation capabilities, SDG Synergies can reveal more complex relationships that are the result of how interactions can ripple through the larger system. For example, visualisations and analyses can inform decisions about how to prioritise or sequence the implementation of different targets based on their systemic impact (what gives the most/least support to achieving progress in all the goals), or where measures may be needed to manage potential trade-offs between them. They can also help to identify what cross-sectoral collaborations would be the most productive by showing groups of strongly linked goals. The scientific basis of the SDG Synergies approach is described in Weitz et al. (2018). The basic idea is understanding the impact and importance of a goal in supporting sustainability requires systems analysis. Each application of SDG Synergies is unique. SDG Synergies has been used in a wide range of different settings on a sub-national, national and regional level (EU). The process could involve scientific experts, representatives of different government sectors, and a range of other stakeholders. As well as benefiting from their unique perspectives, this type of inclusiveness can help to build bridges and partnerships between actors and sectors, generating a shared understanding of the challenges and opportunities, highlighting common interests, and building ownership among stakeholders. These outcomes can be just as valuable as the analytical outputs. Showcasing how the approach can be customised, Barquet et al. (2021) summarised three country studies and Carlsen et al. (2022) demonstrated how the SDG Synergies can be used to support systems thinking in the voluntary national review (VNR) process. Helldén et al. (Helldén et al. 2022) showed an application to child health in Cambodia. More examples can be found at www.sdgsynergies.org, where the tool is freely available. |
The breadth of the contexts in which SDG Synergies has been applied shows the flexibility of the approach for use in multiple settings. This flexibility is necessary as interactions have been shown to be strongly context-specific; how they play out depends on institutional arrangements, natural resources, economic conditions, governance set-ups, the technological options available, current policies and practices, as well as the prevailing ideologies. While every application of SDG Synergies is different, tailored to the context, targets and resources available, they all follow the same methodological steps: contextualisation, scoring of interactions and analysis. This was also the case for the applications described in this chapter. |
The SDG Synergies approach consists of a three-step process of collaborative analysis:
- Contextualisation: Every application of SDG Synergies is unique, and the way in which the interactions play out depends on the context in terms of institutional arrangements, natural resources, economic conditions, governance set-ups, the technological options available, current policies and practices, as well as the prevailing ideologies. Hence, the goals and targets need to be clearly defined in each application of SDG Synergies.
- Scoring interactions: The selected goals from step 1 are transferred into a cross-impact matrix, in which each matrix element (except the diagonal) is used to score the interactions. The guiding question for the scoring is: “If progress is made towards Target X, how does this influence progress towards Target Y?” In this scoring, a scale is applied ranging from +3: strongly promoting progress towards Target Y, via +2: moderately promoting, +1: weakly promoting, 0: no influence, -1: weakly restricting progress towards Target Y, -2: moderately restricting, to -3: strongly restricting (Weimer-Jehle 2006). In the SDG Synergies tool it is also possible to add text to justify or further explain the selected score. An important feature of this excercise is that stakeholders focus on the direct influence between the targets, whereas the secondary effects are taken care of by the software.
- Analysis: In the third step, network analysis methods are used to relate all interactions in the matrix and analyse how progress towards the different goals could affect the whole system. In this step, catalytic targets are identified, i.e. targets that have a positive effect on the system as a whole. Another useful type of analysis in this step is to identify clusters of positively interacting targets and how they might interact with similar clusters. This could serve as a basis for creating cross-sectoral working groups to enhance the development of joint strategies.
SDG Synergies has been applied to a wide range of different cases on a sub-national level, via national and regional levels to an EU level. Showcasing how the approach can be customised, Barquet et al. (2021) summarised three country studies and Carlsen et al. (2022) demonstrated how SDG Synergies can be used to support systems thinking in a voluntary national review (VNR) process. Helldén et al. (2022) showed the application of SDG Synergies to child health in Cambodia.
More examples can be found at www.sdgsynergies.org, where the tool is freely available. The breadth of contexts in which SDG Synergies has been applied indicates the flexibility of the approach for use in multiple settings. We describe its application to the iHAC project below.