Digital Health, Social Enterprise & Citizen Engagement in Integrated People-Centered Health Services: A hermeneutic systematic review and preliminary framework synthesis

Introduction The global commitment to reform primary care systems was reaffirmed in the 2018 Astana Declaration on Primary Health Care. The World Health Organization framework on the Integrated People-Centered Health Services (IPCHS) was designed to implement this agenda, while accelerating progress towards health-focused Sustainable Development Goal (SDG) 3, drive economic growth (SDG 8), and achieve SDGs 1, 2, 4, 5, and 16. However, with the advent of the ‘digital revolution’, emerging socio-technical systems are disrupting existing economic and political systems, producing the ‘Fourth Industrial Revolution’, and potential legitimation crises. Being structurally coupled to major social systems, resilient primary health systems need to incorporate sustainable economic, political and technical solutions: these are social enterprise, citizen engagement and digital health, respectively. This review aimed to develop a preliminary conceptual framework for using Digital Health, Social Enterprise and Citizen Engagement for Integrated People-Centred Health Services. Theory/Methods We conducted a hermeneutic systematic review of theoretical (published & grey) literature to build a comprehensive understanding of digital health, social enterprise and citizen engagement, and their application in health service delivery. Initial searches were used to identify key terms to inform iterative literature searches. Search results were screened and only studies making original theoretical contributions were selected. Coding followed principles of qualitative data analysis, followed by critical interpretive synthesis. The resulting framework was organised within a combination of Donabedian’s ‘structure-process-output’, and Pawson & Tilley’s ‘context-mechanism-outcome’ configurations. Results & Discussion 21 full-text papers were included after screening. The framework that was developed outlined the organisational elements and components required to incorporate digital health, citizen engagement and social enterprise within integrated primary care systems. Existing frameworks contained several mutual elements and conceptual overlaps, such as organisational features (governance, leadership, ecosystem factors), the need for sustainable financing mechanisms, and the pervasive role of digital technology. Digital financial solutions in social enterprise can make health services more inclusive and accessible at the bottom of the economic pyramid; ‘e-participation’ can facilitate citizen engagement in health service design and delivery; and digital health systems are essential to coordinating integrated care services. Citizen engagement and social enterprise are also both crucial for ensuring ‘person-centredness’ of IPCHS. Conclusions There is considerable scope for the integration of Digital Health, Social Enterprise and Citizen Engagement to guide the development of Integrated People-Centred Health Services. While a variety of approaches are possible, the specific combination of interventions will depend on the context of their application. Limitations & Lessons learned As with any framework, this one does not seek to be comprehensive, but to provide an overarching view of how these concepts interact in an organisational context. As this framework is based on secondary data, it requires to be field-tested to ensure its validity.  Future research: Next steps The framework that we have developed will be tested and refined by using a series of primary and secondary case studies; i.e. social enterprises that use digital health and citizen engagement interventions to deliver IPCHS. These findings will enable enhancement of the framework for future testing further afield.