A Framework for Digital Health Policy: Insights From Virtual Primary Care Systems Across Five Nations

Divya Srivastava, Robin Van Kessel, Marine Delgrange, Avi Cherla, Harpreet Sood, Elias Mossialos


Digital health technologies used in primary care, referred to as, virtual primary care, allow patients to interact with primary healthcare professionals remotely though the current iteration of virtual primary care may also come with several unintended consequences, such as accessibility barriers and cream skimming. The World Health Organization (WHO) has a well-established framework to understand the functional components of health systems. However, the existing building blocks framework does not sufficiently account for the disruptive and multi-modal impact of digital transformations.


Digital health technologies represent a growing market share due in part to rapid advances in wireless technology and computing power as well as increasing interest in the application of artificial intelligence (AI) in health systems and service delivery, but also patient interest in having faster and easier access to medical care [1]. Digital health technologies used in primary care (also termed virtual primary care [VPC]) allow patients to interact with primary healthcare professionals remotely and through various modes of communication such as email, text, online chat, video or phone calls [2].

Materials and method

We performed a narrative review to identify gaps in the existing WHO building blocks framework and develop the conceptual framework. Five databases (PubMed, CINAHL, EBSCO, Web of Science, Cochrane Review) and Google Scholar were searched. Articles were included if they comprised empirical research, systematic reviews and review articles and were published between 2011 to the first quarter of 2022. Grey literature was identified through Google (Scholar) searches, websites of national institutions, and institutions that conduct health policy analyses (Table 1). Two authors (DS and MD) undertook the primary literature review and cross-checked each other’s findings.


The narrative review identified forty relevant articles [8–47] (Table 2). The search includes a mix of academic papers (18 articles), grey literature and government documents (twenty-two). Grey literature supplemented the academic research for the five countries in this review.


This article aimed to advance the WHO building blocks framework to be better fit for purpose in the context of digital transformations in health, in particular VPC. Various implementation issues were identified through the updated framework and narrative review for all five countries. First, for-profit telemedicine has been difficult to regulate in some of the countries reviewed, with new arrangements (often temporary) having to be found with the private sector. Second, difficulties with regards to the coordination and continuation of care remain, particularly due to the lack of integration and data sharing between the public and private VPC systems.


In conclusion, the implementation of VPC within a health system is a complex challenge that is contingent on many stakeholders. Our proposed digital health policy framework and guiding principles can be a useful starting point to assess how VPC systems are working in practice. The growing interest in VPC suggests that decision-makers should consider a flexible VPC offer; one that is more appropriate at identifying patients and draws on user experience to inform the design of its delivery, the health impacts and particularly for underserved populations including affordability of digital devices, and connectivity.


Martin Brunninger and the Austrian Insurance of Health & Social Care provided valuable feedback on earlier drafts.

Citation: Srivastava D, Van Kessel R, Delgrange M, Cherla A, Sood H, Mossialos E (2023) A Framework for Digital Health Policy: Insights from Virtual Primary Care Systems Across Five Nations. PLOS Digit Health 2(11): e0000382.

Editor: Haleh Ayatollahi, Iran University of Medical Sciences, IRAN (ISLAMIC REPUBLIC OF)

Received: June 22, 2023; Accepted: October 4, 2023; Published: November 8, 2023

Copyright: © 2023 Srivastava et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

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