Building Sustainable Health Tech Programs in Low-Income Countries

Most health technology programs in low-income countries do not survive their pilot phase. The pattern is familiar to anyone who has worked in global health: a donor funds a promising digital health intervention, a team deploys it across a handful of clinics or community health worker networks, results look encouraging, the funding cycle ends, and the program quietly disappears. A 2019 systematic review published in Global Health: Science and Practice by Huang et al. found that fewer than 5% of mHealth pilot projects in Sub-Saharan Africa had successfully transitioned to sustainable, scaled programs. The numbers have improved somewhat since then, but the underlying problem has not gone away.

The question is not whether health technology works in these settings. There is ample evidence that smartphone-based screening, digital record-keeping, and remote monitoring tools improve health outcomes when they are actually in use. The question is why so many programs fail to stick around long enough to matter.

"The graveyard of global health is full of pilots that worked." — Dr. Alain Labrique, Director of Digital Health, WHO, speaking at the Global Digital Health Forum, December 2023

Why health tech programs in low-income countries collapse

The reasons are structural, not technical. Most programs that fail were built on assumptions that do not hold once external funding dries up.

Donor dependency without an exit plan. The Global Fund invests approximately $150 million annually in digital health across low- and middle-income countries. USAID, the Bill & Melinda Gates Foundation, PEPFAR, and bilateral development agencies contribute billions more. But much of this funding flows to specific projects with defined timelines, usually two to five years. When the grant period ends, there is often no government budget line, no revenue model, and no institutional owner to keep the technology running. A 2025 systematic review by Kaboré et al. published in Frontiers in Digital Health identified donor dependency as the single most cited barrier to sustainability of digital health interventions in LMICs.

Technology that does not fit local infrastructure. Programs designed in Nairobi or Geneva sometimes arrive in rural districts where electricity is intermittent, mobile data costs eat into health worker stipends, and the nearest IT support is a six-hour drive away. A WHO Bulletin article from late 2024 on digitalization of healthcare in LMICs noted that infrastructure gaps, including unreliable connectivity and limited device availability, remain among the most persistent barriers to scaling digital health tools beyond pilot sites.

No government ownership from the start. Programs that treat the Ministry of Health as a passive recipient rather than a co-designer tend to get abandoned when the implementing NGO moves on to the next project. Government ownership is not something you add at the end. It has to be built into the program from the beginning, which means working within existing health information systems, aligning with national digital health strategies, and using platforms the ministry can actually maintain.

Ignoring community health worker economics. Community health workers are the last-mile delivery system for health technology in most low-income countries. But CHW programs are severely underfunded globally. Africa CDC reported in 2024 that there is a $4.4 billion annual funding gap for community health workforce programs across Africa. If the people operating the technology cannot sustain their own livelihoods, the technology will not be sustained either.

What sustainable programs do differently

The programs that survive share several characteristics. None of them are particularly glamorous, which may be why they get less attention than the technology itself.

Factor	Programs that collapse	Programs that last
Funding model	100% donor-funded with no transition plan	Blended: government budget allocation + donor support + fee-for-service elements
Government role	Informed at launch, invited to closing ceremony	Co-designs the program, owns the data, trains their own staff
Technology platform	Custom-built by implementing NGO	Integrated into national health information system (e.g., DHIS2)
Hardware strategy	Provides devices during pilot, no replacement plan	Uses health workers' existing smartphones or government-procured devices with maintenance budgets
Training model	One-time training at launch	Ongoing peer mentorship with local trainers of trainers
Data ownership	Stored on NGO servers, leaves with the project	Hosted on government or locally controlled infrastructure
Community health worker support	Treated as volunteer labor	Compensated, supervised, and integrated into formal health system

Government budget integration

The programs that survive long-term are the ones that get written into government budgets. This sounds obvious but it requires years of advocacy and demonstration. Rwanda has been cited repeatedly as a model: the country's community health program, including its digital components, is funded through a combination of government allocation, performance-based financing, and Global Fund support. The key distinction is that the government owns and operates the program. External funding supplements it rather than creating it.

Kenya offers another example. The country's community health strategy includes a digital health component that the Ministry of Health manages directly. Financing comes from a mix of county government budgets, national health insurance funds, and development partner support. Neither model is perfect, and both still rely partly on external funding, but the institutional ownership means the program does not vanish when a single donor exits.

Integration with existing health information systems

The Health Information Systems Program (HISP), which developed and maintains DHIS2, has been one of the more successful platforms in global health precisely because it is designed for government ownership. DHIS2 is used as the national health information system in over 80 countries. When a digital health intervention plugs into DHIS2 rather than building a parallel data system, it becomes part of the infrastructure the government already maintains.

A 2025 review in the Journal of Medical Internet Research covering 25 years of digital health in LMICs found that programs integrated into national health information infrastructure were significantly more likely to survive beyond their initial funding period than standalone applications. The authors — Salifu et al. — noted that interoperability with existing systems was the most consistent predictor of sustainability across multiple country contexts.

Local technical capacity

One of the less discussed sustainability factors is whether local engineers and IT professionals can maintain and adapt the technology after the implementing organization leaves. Programs that rely entirely on foreign technical teams create a dependency that mirrors the financial dependency problem. The most durable programs invest in building local software development and system administration capacity from the beginning.

The Africa CDC's Lusaka Agenda, adopted in 2024, specifically called out the need for unified planning and country ownership of digital health systems, including building domestic technical capacity. There is concern, as several commentators noted, that fragmented donor ecosystems work against this goal by funding competing platforms that each require specialized skills.

The smartphone screening advantage for sustainability

Smartphone-based health screening has a structural advantage when it comes to program sustainability, and it is worth being specific about why.

Traditional health screening programs in low-resource settings require equipment: blood pressure cuffs, pulse oximeters, thermometers, glucometers, and the consumables that go with them. Each piece of equipment has a lifespan, requires calibration, and needs replacement parts. When the program that supplied them ends, the equipment degrades and is not replaced. A 2024 comparison study on smartphone versus traditional screening costs in LMICs found that equipment replacement and consumable costs were among the top three reasons traditional screening programs failed to sustain operations.

Smartphone-based approaches that use the phone's camera to capture health indicators eliminate much of this hardware dependency. The device the community health worker needs is the same device they already carry. Updates happen over the air. There is no supply chain for consumables. This does not solve every sustainability challenge — you still need training, supervision, data infrastructure, and institutional support — but it removes one of the most common failure points.

Companies like Circadify have developed contactless vital signs screening that works on standard smartphones, which fits this sustainability model. The screening runs on the phone itself, works offline, and does not require any additional hardware.

Financing models that work beyond grants

The conversation about sustainable health tech financing in low-income countries has matured over the past several years. There are now several models being used or piloted.

Performance-based financing. Rwanda, Nigeria, and several other countries have experimented with models where health facilities or CHW programs receive payments tied to health outcomes or service delivery metrics. When digital tools improve those metrics — more screenings completed, more referrals followed up, better data quality — they become worth maintaining because they directly affect revenue.

Government line-item budgeting. Getting a digital health program written into a national or county-level budget is the most straightforward path to sustainability. It is also the slowest. Budget processes in most low-income countries move on annual or biennial cycles, require legislative approval, and compete with every other health priority. Programs that plan for this timeline from the beginning are more likely to succeed.

Blended finance models. Some programs combine government funding, donor grants, social enterprise revenue, and private sector partnerships. The Global Fund has moved toward this approach, increasingly requiring country co-financing as a condition of grants. The idea is that no single funding source is reliable enough on its own, so resilience comes from diversification.

Fee-for-service for non-primary care applications. In some contexts, health screening services for insurance applicants, employer wellness programs, or private clinics can generate revenue that cross-subsidizes public health screening. This is more common in middle-income countries than in the lowest-income settings, but it represents a path that did not exist before smartphone-based screening made the unit economics viable.

What the evidence says about long-term program survival

The research base on this topic has grown substantially. A systematic review published in Authorea in 2024 examining policy planning and implementation challenges for digital health in LMICs concluded that the programs most likely to sustain themselves share three characteristics: inclusive governance that involves government decision-makers from design through implementation, investment in local capacity building, and use of interoperable systems that connect to national health infrastructure.

Separately, the WHO Digital Health Technical Advisory Group has pushed for national digital health strategies that include sustainability planning as a required component. As of 2025, over 120 countries have adopted or are developing national digital health strategies, though the quality and implementation of sustainability provisions varies widely.

The Journal of Global Health Research published a systematic scoping review protocol in 2024 specifically designed to map digital health interventions in primary care across LMICs, noting that understanding diverse political and regulatory environments is essential for identifying what makes programs sustainable in different country contexts. The fact that researchers are still building the methodological frameworks for studying this question tells you something about how early we are in understanding it.

Frequently asked questions

Why do most health tech pilots in low-income countries fail to scale?

The most common reasons are donor dependency without transition planning, technology that does not integrate with existing government health systems, lack of government ownership, and insufficient investment in local human capacity. The Kaboré et al. 2025 review in Frontiers in Digital Health found that these barriers appear consistently across countries and technology types.

What is the role of community health workers in sustainable health tech programs?

Community health workers are typically the end users of health technology in low-income settings. Programs that treat CHWs as unpaid volunteers operating donated technology do not last. Sustainable programs compensate CHWs, provide ongoing training and supervision, and integrate them into the formal health system. Africa CDC's estimate of a $4.4 billion annual funding gap for CHW programs in Africa indicates the scale of the investment needed.

How does smartphone-based screening improve sustainability?

Smartphone-based screening reduces dependence on specialized equipment, consumables, and supply chains that typically break down when external funding ends. Because community health workers already own or can access smartphones, the hardware barrier is lower. Software updates happen remotely, and no calibration or replacement parts are needed.

Which financing models work best for sustaining health tech in low-income countries?

No single model works everywhere. The most resilient programs use blended financing that combines government budget allocations, performance-based payments, donor support, and where possible, fee-for-service revenue. The common thread in programs that survive is that government funding represents a growing share of total costs over time, reducing dependence on any single external funder.