37521 Improving health, connecting people: the role of ICTs in the health sector of developing countries A framework paper Edited by Andrew Chetley; with contributions by Jackie Davies, Bernard Trude, Harry McConnell, Roberto Ramirez, T Shields, Peter Drury, J Kumekawa, J Louw, G Fereday, Caroline Nyamai-Kisia InfoDev Task Manager: J. Dubow 31 May 2006 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 1 Executive Summary This framework paper is aimed at policy makers who are involved in the development or management of programmes in the health sector in developing countries. It provides a `snapshot' of the type of information and communication technology (ICT) interventions that are being used in the health sector, and the policy debates around ICTs and health. It draws from the experience of use in both the North and South, but with a focus on applicability in the South to identify the most effective and relevant uses of ICTs. The paper describes the major constraints and challenges faced in using ICTs effectively in the health sector of developing countries. It draws out good practice for using ICTs in the health sector, identifies major players and stakeholders and highlights priority needs and issues of relevance to policy makers. The paper also looks at emerging trends in technologies that are likely to shape ICT use in the health sector and identifies gaps in knowledge. For the purposes of this paper, ICTs are defined as tools that facilitate communication and the processing and transmission of information by electronic means. This definition encompasses the full range of ICTs, from radio and television to telephones (fixed and mobile), computers and the Internet. This paper sees health as a complex interaction of biomedical, social, economic, and political determinants. It places the discussion of health firmly in the poverty and development debates and pays particular attention to how ICTs can best be used to move towards achievement of the Millennium Development Goals (MDGs), as part of poverty reduction strategies and in order to improve the health of the most poor and vulnerable people. There has been considerable international discussion about the potential of ICTs to make major impacts in improving the health and well being of poor and marginalized populations, combating poverty, and encouraging sustainable development and governance. Used effectively ICTs have enormous potential as tools to increase information flows and the dissemination of evidence-based knowledge, and to empower citizens. However, despite all its potential, a major challenge is that ICTs have not been widely used as tools that advance equitable healthcare access. A critical mass of professional and community users of ICTs in health has not yet been reached in developing countries. Many of the approaches being used are still at a relatively new stage of implementation, with insufficient studies to establish their relevance, applicability or cost effectiveness (Martinez, et al, 2001). This makes it difficult for governments of developing countries to determine their investment priorities (Chandrasekhar and Ghosh, 2001). However, there are a number of pilot projects that have demonstrated improvements such as a 50% reduction in mortality or 25-50% increases in productivity within the healthcare system (Greenberg, 2005). The examples in this paper show that ICTs have clearly made an impact on health care. They have: · Improved dissemination of public health information and facilitated public discourse and dialogue around major public health threats · Enabled remote consultation, diagnosis and treatment through telemedicine · Facilitated collaboration and cooperation among health workers, including sharing of learning and training approaches · Supported more effective health research and the dissemination and access to research findings This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 2 · Strengthened the ability to monitor the incidence of public health threats and respond in a more timely and effective manner · Improved the efficiency of administrative systems in health care facilities. This translates into savings in lives and resources and direct improvements in people's health. In Peru, Egypt and Uganda, effective use of ICTs has prevented avoidable maternal deaths. In South Africa, the use of mobile phones has enabled TB patients to receive timely reminders to take their medication. In Cambodia, Rwanda, South Africa and Nicaragua, multimedia communication programmes are increasing awareness of how to strengthen community responses to HIV and AIDS. In Bangladesh and India, global satellite technology is helping to track outbreaks of epidemics and ensure effective prevention and treatment can reach people in time. Experience demonstrates that there is no single solution that will work in all settings. The complexity of choices of technologies and the complexity of needs and demands of health systems suggests that the gradual introduction, testing and refining of new technologies, in those areas of health care where there is a reasonable expectation that ICTs can be effectively and efficiently used, is more likely to be the successful way forward. Some innovative leaps may also be possible as technology is evolving rapidly. Wireless applications, increased use of mobile telephony and combinations of technology working together are some of the trends identified in this paper that suggest new opportunities. The paper concludes that opportunities do exist for the use of ICTs in the health sector of developing countries; however a number of issues must be carefully considered in each intervention and setting: · To what degree is the health sector structure and the national regulatory framework conducive to problem-oriented, interdisciplinary, rapid-response collaborative technical work and to implementing the political, regulatory, and managerial tasks required to address multifaceted and complex technological problems? · Have a vision, goals, action plan and potential outcomes and benefits been clearly defined? · Are there mechanisms for coordinating action led by the public sector, but in a way that links public, private and social efforts and engages with diverse stakeholders to speed the development and use of priority ICT solutions? · Are there incentives for telecommunication sector reform processes? · Are data-related standards and a regulatory and legal framework in place? · Are there mechanisms for developing the capacity of health workers, other intermediaries and community members to make the most effective use of the ICTs available and to develop content that is relevant, applicable and culturally appropriate? · What options exist to ensure continuity and sustainability of ICT projects and programmes in terms of finance flows, public-private partnerships and building on existing information and communication channels and resources? Seven broad conclusions can be drawn about the use of ICTs in the health sector. These seven should be applicable at all levels, and although they are expressed simply here, the complexity of putting them into practice is one of the biggest challenges that has to be faced in ensuring health system benefit; health workers benefit; the people who make use of the health system ­ the patients and citizens ­ benefit and their health improves. The seven conclusions are: 1. Keep the technology simple, relevant and local. 2. Build on what is there (and being used). 3. Involve users in the design (by demonstrating benefit). This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 3 4. Strengthen capacity to use, work with and develop effective ICTs. 5. Introduce greater monitoring and evaluation, particularly participatory approaches. 6. Include communication strategies in the design of ICT projects. 7. Continue to research and share learning about what works, and what fails. The paper also highlights several major areas where not enough is known and where further experimentation, research and analysis are needed, including: · how to move from proof of concept to large-scale implementation in a range of different settings? · how to evaluate systematically and coherently the impact of the use of ICTs on health? · how to share information and experience and coordinate efforts (at national, regional and international levels) around the use of ICTs in the health sector? · what can be done to strengthen the role of and build the capacity of intermediaries? · how to develop local content that is relevant, appropriate and practical? · how to strengthen organisational and national human resources, awareness skills and leadership to champion the further development of ICT use in the health sector? · how to enable the voices of those most affected by poor health to be heard? · how to implement the range of standards and a regulatory and legal framework that is conducive to the development of a vibrant ICT sector that responds to and supports social development processes? These questions help to set out an agenda for future action to enable ICTs to contribute to efforts to improve health and to achieve the health-related Millennium Development Goals (MDGs). Section 1 outlines the aims, audience and scope of this paper. Section 2 provides a broad introduction to the information and communication technologies, highlights the way in which they can be used as one of the tools to help meet the health- related MDGs, explores the need to build on evidence and identifies the many beneficiaries, intermediaries and other stakeholders who are involved in the effective use of ICTs in the health sector. Section 3 explores potential and actual use of ICTs in the health sector. It examines the ways in which ICTs can help to strengthen four main pillars of any health system ­ information, management of health services, human resources, and financing. Section 4 highlights eight major constraints and challenges that need to be faced in integrating the use of ICTs into the work of the health sector. Section 5 identifies emerging technological trends that may shape future use of ICTs in the health sector, particularly exploring those uses that help to extend the reach of the health system to rural and difficult to reach settings and approaches that may help to increase the involvement of patients and citizens who are most vulnerable to the impact of ill health. Section 6 draws out key lessons. Section 7 identifies the major areas where further exploration is needed to build a stronger evidence base of how to use ICTs effectively in the health sector in developing countries. Section 8 gives the references used in this paper. A complete annotated bibliography and knowledge map that this paper draws upon is available at www.asksource.info/res_library/ict.htm. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 4 Acknowledgements This paper forms part of a body of work commissioned in August 2005 by infoDev under grant 1254, and undertaken by Healthlink Worldwide and partners, to look at the use of ICTs in the health sector in developing countries. The infoDev Task Manager was Jacqueline Dubow. The study was implemented by a consortium of Healthlink Worldwide (www.healthlink.org.uk), AfriAfya (www.afriafya.org) and the Institute for Sustainable Health Education and Development (ISHED ­ www.ished.org). Thanks particularly to Jacqueline Dubow, Richard Heeks, Renu Barry, Nick Haazen, Ulla Hauer, Adesina Iluyemi, Stephen Settimi, Richard Martin, Dale Hill, Kerry MacNamara and Ludewijk Bos, who reviewed the publication and offered useful suggestions for its improvement. Thanks also to the Advisory Group set up for the entire study who helped to inform the research, contributed to the online discussion and offered useful suggestions for the framework paper. Thanks are also due to staff at the World Health Organization who participated in a one-day review discussion of an early draft of the paper and helped to clarify many of its sections. Ibrahima Bob, Sarah Greenley, James Kimani, Ligia Macias, Margaret Nyambura Ndung'u and Lenny Rhine were part of the research team. H McConnell, T Shields, P Drury, J Kumekawa, J Louw, G Fereday, Caroline Nyamai-Kisia, Margaret Nyambura Ndung'u, Roberto Rodrigues and Bernard Trude drafted various sections of the report. Andrew Chetley and Jackie Davies were responsible for compiling and editing the final version. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 5 Contents 1. USING THE FRAMEWORK PAPER .................................................................................................. 8 1.1 THE AIMS OF THE PAPER ................................................................................................................................ 8 1.2 THE AUDIENCE FOR THIS PAPER..................................................................................................................... 8 1.3. THE SCOPE.................................................................................................................................................... 8 2. INTRODUCTION............................................................................................................................... 11 2.1 ICTS AND THE HEALTH-RELATED MDGS .................................................................................................... 12 2.2 BUILDING ON EVIDENCE .............................................................................................................................. 13 2.3 BENEFICIARIES AND INTERMEDIARIES ......................................................................................................... 13 2.3.1 Beneficiaries........................................................................................................................................ 14 2.3.2 Intermediaries ..................................................................................................................................... 14 2.3.3 Key Lessons......................................................................................................................................... 15 3. USING ICTS IN THE HEALTH SECTOR ......................................................................................... 16 3.1 IMPROVING THE FUNCTIONING OF HEALTH CARE SYSTEMS.......................................................................... 18 3.1.1 Key lessons.......................................................................................................................................... 20 3.2 IMPROVING HEALTH CARE DELIVERY........................................................................................................... 20 3.2.1 Telemedicine........................................................................................................................................ 21 3.2.2 E-learning............................................................................................................................................ 22 3.2.3 Key Lessons......................................................................................................................................... 25 3.3 IMPROVING COMMUNICATION AROUND HEALTH.......................................................................................... 25 3.3.1 Information via the internet and other ICT media............................................................................... 25 3.3.2 Increasing effectiveness of communication systems............................................................................ 27 3.3.3 Greater access to communication tools and opportunities ................................................................. 28 3.3.4 Increasing interaction, participation and amplifying `voices' ............................................................ 29 3.3.5 Key Lessons......................................................................................................................................... 30 4. CONSTRAINTS AND CHALLENGES.............................................................................................. 31 4.1 Connectivity............................................................................................................................................ 31 4.2 Content ................................................................................................................................................... 32 4.3 Capacity ................................................................................................................................................. 33 4.4 Community ............................................................................................................................................. 34 4.5 Commerce .............................................................................................................................................. 34 4.6 Culture.................................................................................................................................................... 35 4.7 Cooperation............................................................................................................................................ 35 4.8 Capital.................................................................................................................................................... 36 5. EMERGING TRENDS AND POTENTIAL IMPACT OF ICTS........................................................... 38 5.1 EMERGING TRENDS...................................................................................................................................... 38 5.1.1 Wireless access.................................................................................................................................... 38 5.1.2 Telephony ............................................................................................................................................ 38 5.1.3 Radio ................................................................................................................................................... 39 5.1.4 Digital video........................................................................................................................................ 40 5.1.5 Convergence and combination of technologies................................................................................... 40 5.1.6 Continual technological development ................................................................................................. 42 5.2 POTENTIAL IMPACT ON INDIVIDUAL BEHAVIOUR AND DECISION MAKING.................................................... 42 6. LESSONS ......................................................................................................................................... 45 6.1 SUMMARY OF KEY LESSONS ABOUT THE USE OF ICTS IN HEALTH................................................................ 46 6.2 CRITICAL REQUIREMENTS FOR SUCCESSFUL IMPLEMENTATION OF HEALTH ICTS........................................ 47 6.3 LESSONS ABOUT WHY HEALTH ICT PROJECTS FAIL ..................................................................................... 48 6.4 LESSONS ABOUT KNOWLEDGE GAPS ............................................................................................................ 48 6.5 LESSONS ABOUT STAGED DEVELOPMENT..................................................................................................... 50 6.5.1 A context specific approach ................................................................................................................ 50 6.5.2 A step change framework .................................................................................................................... 51 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 6 7. CONCLUSIONS................................................................................................................................ 52 8. REFERENCES.................................................................................................................................. 53 APPENDIX 1: BODY OF EVIDENCE................................................................................................... 59 APPENDIX 2: TERMS OF REFERENCE............................................................................................. 62 APPENDIX 3: METHODOLOGY .......................................................................................................... 64 TABLE 1: KEY ASPECTS OF THE WHO EHEALTH STRATEGY.................................................................................. 16 TABLE 2: POTENTIAL USES OF ICTS IN THE HEALTH SECTOR AND ISSUES THAT MAY EMERGE............................... 17 TABLE 3: CONNECTIVITY ACCESS 2004 ................................................................................................................. 31 TABLE 4: SELECTED TECHNOLOGY INPUTS BY REGION (1992-1997) .................................................................... 33 TABLE 5: REPRODUCTIVE HEALTH ACTIVITIES BENEFITING FROM ICTS ................................................................ 43 TABLE 6: LESSONS AND POSSIBLE ACTIONS........................................................................................................... 45 EXAMPLE 1: DEVELOPING HEALTH INFORMATION SYSTEMS IN SOUTH AFRICA................................ 19 EXAMPLE 2: AMREF: USING TELEMEDICINE TO IMPROVE RURAL HEALTH ...................................... 21 EXAMPLE 3: IMPROVING ACCESS TO INFORMATION IN INDIA .......................................................... 22 EXAMPLE 4: DISTANCE EDUCATION RADIO FOR HEALTH WORKERS IN NEPAL ................................. 23 EXAMPLE 5: ELECTRONIC NETWORKING AND COMMUNICATION SUPPORT ON HIV AND AIDS .......... 23 EXAMPLE 6: USING PDAS IN AFRICA ­ SATELLIFE'S EXPERIENCE................................................. 24 EXAMPLE 7: MULTI-MEDIA HEALTH PROMOTION IN NICARAGUA ..................................................... 26 EXAMPLE 8: DEVELOPING QUICK RESPONSES IN INDIA ................................................................. 27 EXAMPLE 9: PREVENTING ILLNESS IN UGANDA............................................................................. 27 EXAMPLE 10: CREATIVE USE OF PHONES IN BANGLADESH AND UGANDA....................................... 28 EXAMPLE 11: HEALTH INFORMATION DISSEMINATION CENTRES IN EAST AND SOUTHERN AFRICA.... 33 EXAMPLE 12: WIRELESS INTERNET ACCESS IN RURAL INDIA ........................................................ 38 EXAMPLE 13: MOBILE PHONES KEEP TRACK OF HIV AND TB TREATMENTS.................................... 39 EXAMPLE 14: AFRIAFYA ­ WORKING WITH A COMBINATION OF ICTS ............................................. 41 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 7 1. Using the framework paper 1.1 The aims of the paper The aim of this framework paper is to draw recommendations on priority issues and future trends for policy makers. The paper draws on information gathered during the process of mapping and dialogue/discussion to present analysis and make recommendations about priority issues related to ICTs in the health sector. The paper organizes the issues and identifies key questions, players and constraints; it presents an informed overview of ICTs and health from a development perspective, and identifies good practice examples of the use of ICTs in the health sector. It also outlines challenges facing the development of ICT implementation in health programmes and activities, and identifies the emerging trends and technologies that will shape ICT tools in the health sector. The analysis is presented on an international and regional level, as well as on a country and community level according to the examples examined during the research phase. The paper synthesises guidelines and good practices in broad terms for using ICTs in the heath sector; and focuses on the cost- effectiveness of ICT-supported activities, and the use of ICTs for better monitoring of health- related MDGs. This framework paper is part of a set of activities implemented by Healthlink Worldwide and partners for InfoDev. These activities included a knowledge mapping exercise and an expert analysis to produce a paper that presents the current knowledge on the role and use of ICTs in the health sector and outlines knowledge gaps. Mapping and consultation activities included the development of a knowledge map with an annotated bibliography and the running of an online discussion (Please see the Source website for a presentation of each of these project outputs: http://www.asksource.info/res_library/ict.htm). 1.2 The audience for this paper The audience for this paper are policy makers in developing countries and donors working in the health sector. However it also has value for other health and development leaders, such as health institution managers and practitioners from the local to international level. 1.3. The scope This framework paper is intended as an introductory exploration of the subject of ICTs and health, from the perspective of policy. It does not seek to comprehensively catalogue or analyse the full spectrum of issues and data that exist in the field of ICTs and health as this would be impossible within the scope of the research project. It does seek however to perform an initial sweep of sources and information that are in the public realm about ICTs and health, and also to gather content and learning that is within institutions. This research data then informed a summary of the empirical situation regarding ICT strategies and projects in health in the developing world, as well as proposing an analysis about what is known, and what still remains unknown in this field. Based on this overview of the knowledge map of the subject a number of recommendations are put forward. The scope of the exercise is limited in terms of time and resources, as outlined in the Terms of Reference (see Appendix 3). It is anticipated that this overview will encourage and signpost further research and inquiry in specific sub-topics within ICTs and health. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 8 1.4 Acronyms used AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy ARVs Antiretrovirals BBC British Broadcasting Corporation BCC Behaviour Change Communication CFSC Communication for Social Change CSO Civil Society Organisation DFID Department for International Development FAO UN Food and Agricultural Organisation FBOs Faith Based Organisations FHI Family Health International GFATM Global Fund for AIDS, TB and Malaria HDR Human Development Report HIV Human Immunodeficiency Virus ICTs Information and communication technologies IEC Information, Education and Communication MAP Multi-country AIDS Programme MDGs Millennium Development Goals NGO Non-governmental Organisation PLWHA People living with HIV and AIDS PMTCT Prevention of Mother to Child Transmission STI Sexually Transmitted Infection TAC Treatment Action Campaign UNAIDS Joint UN Programme on HIV and AIDS UNESCO UN Educational Scientific and Cultural Organisation USAID United States Agency for International Development VCT Voluntary Counselling and Testing WHO World Health Organization WTO World Trade Organization 1.5 Definitions used Information and communication technologies (ICTs) ICTs have been defined by different commentators in various ways (UN ICT Task Force, 2003; Skuse, 2001; Michiels and Van Crowder, 2001; World Bank, 2003; Greenberg, 2005 and Weigel and Waldburger, 2004). Many definitions focus particularly on the `newer' computer-assisted, digital or electronic technologies, such as the Internet of mobile telephony. Some do include `older' technologies, such as radio or television. Some even include the whole range of technologies that can be used for communication, including print, theatre, folk media and dialogue processes. Some focus only on the idea of information handling or transmission of data. Others encompass the broader concept of being tools to enhance communication processes and the exchange of knowledge. For the purposes of this study, ICTs are defined as tools that facilitate communication and the processing and transmission of information and the sharing of knowledge by electronic means. This encompasses the full range of electronic digital and analog ICTs, from radio and television to telephones (fixed and mobile), computers, electronic-based media such as digital text and audio-video recording, and the Internet, but excludes the non- electronic technologies. This does not lessen the importance of non-electronic technologies such as paper-based text for sharing information and knowledge or communicating about health, but merely draws a boundary around the field addressed by this document. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 9 Medical, health, and healthcare informatics These terms first appeared in the 1960s, and refer to the knowledge, skills and tools which enable information to be collected, managed, used and shared to support the delivery of healthcare and to promote health (NHS, 2006) Medical/health technologies A simple definition, produced by WHO (2004) is that health technologies are solutions to health problems. They are essential any tool, device or procedure used in health care. This can include ICTs, and when it does, these are usually categorised as: · Diagnostic Technologies - electrocardiography, electroencephalography, myography, x-ray imaging, fiberoptic endoscopy, computerized tomography, magnetic resonance imaging, ultrasonography, coronary angiography, non-invasive functional organ studies, radionuclide uptake and imaging diagnostic procedures, biochemical, hematological, serological, microbiological, and tissue pathology analytical studies, genetic analysis. · Therapeutic Technologies - including curative and preventive technologies such as pharmaceuticals, laparoscopic and laser surgery techniques, vaccination, radiation by external sources or radionuclides, and the evolving applications of genetic engineering and gene therapy to human disease, · Information Technologies - including manual and computerized data systems, medical records, clinical and administrative documentation, communication resources, fax machines, telephone, e-mail, the internet, handheld computers and portable digital assistants (PDAs), electronic medical records, and "smart cards". Telemedicine, Health Telematics Telemedicine is the delivery of health care services, where distance is a critical factor, by health care professionals using information and communication technologies for the exchange of vital information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interest of advancing the health of individuals and their communities (WHO, 2004). WHO also describes health telematics as a composite term for health-related activities, services and systems, carried out over a distance by means of ICTs, for the purposes of global health promotion, disease control, and health care, as well as education, management and research for health. More restrictive terms that are part of telemedicine include: teleconsultation, telediagnosis, remote second opinion, teleradiology, telesurgery, telecare, teleducation and teletraining. E-health E-health is the use of emerging information and communication technology, especially the Internet, to improve or enable health and healthcare (Eng, 2001). This term bridges both the clinical and non-clinical sectors and includes equally individual and population health- oriented tools. Eysenbach (2001) elaborated on this further and Pagliari, et al (2005) explored the literature to identify 36 definitions of e-health before refining Eysenbach's to read: `e-health is an emerging field of health informatics, referring to the organisation and delivery of health services and information using the Internet and related technologies. In a broader sense, the term characterises not only a technical development, but also a new way of working, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology'. Health system The health system includes all activities whose primary purpose is to promote, restore or maintain health. This includes, but is not limited to, the preventive, curative and palliative health services provided by the health care system (WHO, 2000). This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 10 2. Introduction In developing countries, preventable diseases and premature deaths still inflict a high toll. Inequity of access to basic health services affects distinct regions, communities, and social groups. Under-financing of the health sector in most countries has led to quantitative and qualitative deficiencies in service delivery and to growing gaps in facility and equipment upkeep. Inefficient allocation of scarce resources and lack of coordination among key stakeholders has made duplication of efforts, overlapping responsibilities, and resource wastage common and troublesome problems. Most countries are at some stage of health sector reform to try to provide expanded and equitable access to quality services while reducing or at least controlling the rising cost of healthcare. Health reform processes have many facets and there is no single model being adopted by all countries (PAHO, 1998). However, ICTs have the potential to make a major contribution to improving access and quality of services while containing costs. Improving health involves improving public health and medical programmes designed to provide elective, emergency and long-term clinical care, educating people, improving nutrition and hygiene, and providing more sanitary living conditions. These in turn ultimately involve massive social and economic changes, as many health challenges go well beyond the health sector. The health sector has always relied on technologies. According to WHO (2004), they form the backbone of the services to prevent, diagnose and treat illness and disease. ICTs are only one category of the vast array of technologies that may be of use. Given the right policies, organisation, resources and institutions, ICTs can be powerful tools in the hands of those working to improve health (Daly, 2003). Advances in information and computer technology in the last quarter of the 20th century have led to the ability to more accurately profile individual health risk (Watson, 2003), to understand better basic physiologic and pathologic processes (Laufman, 2002) and to revolutionise diagnosis through new imaging and scanning technologies. Such technological development, however, demands an increased responsibility of practitioners, managers, and policy-makers for assessing the appropriateness of new technologies (Hofmann, 2002). The methods people use to communicate with each other have also changed significantly. Mobile telephony, electronic mail and videoconferencing offer new options for sharing perspectives. Digital technologies are making visual images and the voices of people more accessible through radio, TV, video, portable disk players and the Internet, that change the opportunities for people to share opinions, experience and knowledge. This has been coupled with steps to deregulate the telecommunications and broadcast systems in many countries, which open up spaces and platforms, such as community radio, for increased communication. Reliable information and effective communication are crucial elements in public health practices. The use of appropriate technologies can increase the quality and the reach of both information and communication. On one hand, the knowledge base is about information, which enables people to produce their own health. On the other hand, social organisations help people to achieve health through health care systems and public health processes. The ability of impoverished communities to access services and engage with and demand a health sector that responds to their priorities and needs, is importantly influenced by wider information and communication processes, mediated by ICTs. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 11 2.1 ICTs and the health-related MDGs Health is at the heart of the Millennium Development Goals (MDGs) - recognition that health is central to the global agenda of reducing poverty as well as an important measure of human development (WHO, 2005). Three of the eight MDGs are directly health-related: · reduce child mortality (goal 4) · improve maternal health (goal 5) · combat HIV and AIDS, malaria and other diseases (goal 6) The other MDGs include health related targets and reflect many of the social, economic, environmental and gender-related determinants that have an impact on people's health. Achieving them will also contribute to improvements in the health status of thousands of millions of people around the world: · eradicate extreme poverty and hunger (goal 1) · improve education (goal 2) · empower and educate women (goal 3) · improve water and sanitation systems (a key component of goal 7) · improve international partnerships (among other things to improve access to affordable, essential drugs on a sustainable basis ­ goal 8) The eight MDGs do not work in isolation and therefore cannot be treated in isolation. Policy efforts and discussions need to consider the broader health determinants that impact upon people's lives (WHO, 2005). UNICEF (1998), for example, has developed a conceptual model for child morbidity and mortality that considers the political, economic and social systems that determine how resources are used and controlled. This helps to identify the number and distribution of children who do not have sufficient access to food, child care, clean water, sanitation and health services. Analysis such as this is applicable to other public health issues, such as HIV and AIDS or women's health (Global Health Watch, 2005). Unless resources are also devoted to tackling the broader determinants of health, more health spending does not necessarily mean better health (Clemens and Moss, 2005). The role that ICTs might be able to play in meeting the MDGs is summarised in Box 1. A comprehensive approach is required, both in terms of looking at issues that cut across different areas and also having private, government and non-governmental organisations working together to achieve the same objectives (World Bank, 2003). ICTs need to work in synergy with any other policy initiatives or strategies, such as national poverty reduction strategies (Danida, 2005) or as part of national health policies. 1. The role of ICTs in meeting the MDGs The OECD (2003), DFID (Marker, et al, 2002), the World Bank (2003), and SIDA (Greenberg, 2005) are among the main development actors who have explored the connection between ICTs and efforts to reduce poverty and achieve the other MDGs. The main conclusion of all these studies is that ICTs, when incorporated effectively into development programmes can be useful tools in efforts to reach the MDGs. The World Bank (2003) argues that there is growing evidence of the ability of ICTs to: · provide new and more efficient methods of production · bring previously unattainable markets within the reach of the poor · improve the delivery of government services · facilitate management and transfer of knowledge. SIDA adds that, increasingly, examples can be found `where the thoughtful use of ICTs has markedly addressed various aspects of poverty. Despite the various pitfalls associated with deploying ICT projects, there is growing evidence that the use of ICTs can be a critical and required component of addressing some facets of poverty. It is This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 12 quite clear that ICTs themselves will not eradicate poverty, but it is equally clear that many aspects of poverty will not be eradicated without the well thought-out use of ICTs.' (Greenberg, 2005) It is difficult, if not impossible, to establish `proven empirical links' between the use of ICTs and the achievement of the MDGs. As the UN ICT Task Force (2003) points out: `measuring the impact of ICT on health generally seems to be fairly difficult because there are obviously many other factors that impact health'. Sources: The OECD (2003), DFID (Marker, et al, 2002), the World Bank (2003), and SIDA (Greenberg, 2005) 2.2 Building on evidence The ideal for policy setting in any area is to rely on a strong evidence base of what works and what does not work. In the case of ICTs and health, strong evidence-based information that draws on impact assessments or outcome measurements is not easy to find. Published evidence there is about the use of ICTs in health tends to be at the proof of concept stage ­ the idea of using a particular technology in relation to a particular medical condition or within an area of the health care system has been shown to work. However, it is harder to find examples of analysis that moves beyond the project purpose to look at the particular processes that might lead to achievement of international development objectives ­ such as the MDGs ­ or to look at the conditions that might need to be in place to scale up the intervention and what might be the impact of such activity (Batchelor and Norrish, 2005). This is where it is essential to look also at analysis of pooled experience and consensus statements and policies. This framework paper draws on both streams of knowledge to develop guidance and to identify gaps. According to WHO (2004), `health technologies are evidence-based when they meet well- defined specifications and have been validated through controlled clinical studies or rest on a widely accepted consensus by experts'. Appendix 2 lists major systematic reviews of the evidence base for the use of ICTs in health over the past five years. Taken together this demonstrates the level of evidence for specific uses of ICTs in health care. While the majority of studies have been done in industrialised countries, they come from a variety of different situations and many of these conclusions could have applicability in other settings. Nearly all of the reviews indicate that there are useful applications for ICTs in health care. Some have been able to identify positive outcomes at the population level. Several also provide concrete suggestions for policy makers and donors. These include that policy makers should be cautious about recommending increased use and investment in unevaluated technologies. As well, the use of ICTs is growing in many areas of health communication, including consumer, patient and provider education; decision and social support; health promotion; knowledge transfer; and the delivery of services (Suggs, 2006). 2.3 Beneficiaries and intermediaries In considering ICTs in health it is vital to be clear about who the potential beneficiaries may be for various strategic options. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 13 2.3.1 Beneficiaries A wide range of stakeholders within key health institutions, and within society as a whole, in the developing world are potential beneficiaries of ICTs. From the literature it is clear that these stakeholders within health institutions need to be clearly identified. It is important to examine individuals and groups within the key institutions in the health system as target beneficiaries for ICTs, and in doing so to examine the issue of their capacity and needs, and the potential for ICTs to assist in efficiency and effectiveness at each level in the system. These beneficiaries can be grouped as follows: · International level: International agencies (WHO, UNAIDS), donor agencies, international NGOs · Regional level: regional bodies, (EU, NEPAD, AU), regional NGOs · National and provincial level: government ministries, national NGOs, national and provincial government, provincial hospitals and health departments · Local level: personnel at health clinics, health workers, doctors, traditional healers, community leaders, patients and citizens. Beneficiaries in health range from individual and collective groups of patients and health workers, through to national and international policy makers. Strategies that address beneficiary needs, that are researched and investigated thoroughly have the greatest potential to succeed. Conversely strategies that are not embedded in clear and realistic needs are vulnerable to failure due to lack of participation, acceptance, capacity and other absent enabling factors. Beneficiaries can also be viewed through the prism of location and access, with an urban/rural differential. It is significant to see the way ICTs can enable the extension of access to health care from the urban to rural areas, helping to connect people to advice and information. This includes people being able to access their own health care information, and health care workers who are in the more remote settings being able to link with colleagues who have access to better facilities and information sources to get advice and support. A suggested tool for decision-makers in strategising about target beneficiaries generally, and beneficiaries within key institutions in health in particular, is to map out as much of the detail of these targets as possible, This could include the range of roles at each level within the target institutions, the capacity of the stakeholders, compared to the necessary capacity required for different types of ICT intervention. Also mapping what is the short, medium and long-term vision for sustainability of the ICT intervention within the target beneficiary group is highly recommended. (Please see `Appendix 1: tools and resources' for examples of templates for mapping). 2.3.2 Intermediaries Intermediaries are the people facilitating health service provision, information and communication for ordinary people on the ground; they may be professional or non- professional, part of the community or outside the community. The one unifying aspect of intermediaries is that they are a link between a higher technical level and the grassroots. Intermediaries include: · communication intermediaries, such as radio personnel and other local media · health service intermediaries, such as local health workers and clinic staff · advocacy and campaigning intermediaries (who are a conduit between policy makers and the grassroots and visa versa). Effective intermediaries in health require training in order to use the technology to create effective interactions. ICTs are not simply neutral conduits of technical information, but require skilled and sensitive communicators to facilitate interactions. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 14 2.3.3 Key Lessons Key lessons about intermediaries and beneficiaries of ICTs in health therefore include: · Each level of beneficiary needs to be considered in terms of their: needs, capacity, location and access within an urban/rural differential. · Intermediaries need to have the capacity to take on the new ICT innovation, without this capacity the innovation will not translate into an embedded and sustainable benefit · Before an ICT strategy is progressed, the target beneficiaries need to be clearly identified and their needs clearly mapped preferably using a participatory approach. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 15 3. Using ICTs in the health sector According to WHO, the use of ICTs in health is not merely about technology (Dzenowagis, 2005), but a means to reach a series of desired outcomes: · health workers making better treatment decisions · hospitals providing higher quality and safer care · people making informed choices about their own health · governments becoming more responsive to health needs · national and local information systems supporting the development of effective, efficient and equitable health systems · policy makers and the public aware of health risks · people having better access to the information and knowledge they need for better health. The evidence regarding ICTs in health is usefully viewed with reference to the key aspects of the WHO eHealth strategy, summarised in Table 1. Table 1: Key aspects of the WHO eHealth Strategy Policy - Ensure public policies support effective and equitable eHealth systems. - Facilitate a collaborative approach to eHealth development. - Monitor internationally-accepted goals and targets for eHealth. - Represent the health perspective in international fora on major ICT issues. - Strengthen ICT in health education and training in countries, supporting a multilingual and multicultural approach Equitable access - Commitment by WHO, Member States and partners to reaching health communities and all populations, including vulnerable groups, with eHealth appropriate to their needs. Best use - Analyze eHealth evolution, impact on health; anticipate emerging challenges and opportunities. - Provide evidence, information and guidance to support policy, best practice, and management of eHealth systems and services. - Identify and address needs for eHealth norms and standards, innovation and research. Source: World Health Organisation (WHO), 2004. ICTs have been used in various ways to contribute to achieving outcomes such as these. Table 2 sets out some of the potential uses identified by Pagliari and her colleagues in 2001. Any health system needs to rest on basic pillars. Four key ones ­ identified by the Disease Control Priorities Project in its latest publication, Priorities in Health (Jamison, 2006) ­ are: · information, surveillance and research · management of health services · human resources · financing. Clearly each of these pillars can benefit from the use of ICTs. In practice, the use of ICTs in the health sector has tended to focus on three broad categories that incorporate these pillars: 1. improving the functioning of health care systems by improving the management of information and access to that information, including: · management of logistics of patient care · administrative systems · patient records This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 16 · ordering and billing systems 2. improving the delivery of health care through better diagnosis, better mapping of public health threats, better training and sharing of knowledge among health workers, and supporting health workers in primary health care, particularly rural health care, including: · biomedical literature search and retrieval · continuing professional development of health workers · telemedicine and remote diagnostic support · diagnostic imaging · critical decision support systems · quality assurance systems · disease surveillance and epidemiology 3. improving communication about health, including improved information flows among health workers and the general public, better opportunities for health promotion and health communication and improved feedback on the impact of health services and interventions, including: · patient information · interactive communication · media approaches · health research · advocacy to improve services. Each of these three categories will be explained in more detail in the following pages with examples of practice and key lessons and recommendations. Table 2: Potential uses of ICTs in the health sector and issues that may emerge What issues currently dominate eHealth? What emerging How does research How do What is going on in eHealth? technologies are inform eHealth? developments in likely to impact on eHealth inform health care? research? Professional Electronic Consumer New Technologies Research Input Research Clinical Patient/Health Health - Satellite - Development - Outcomes Informatics Records (EPR, Informatics communications (for Need for user - Potential of - Decision aids for EHR) - Decision aids for remote medicine ) involvement in electronic databases practitioners - Electronic patients facing - Wireless networks product conception, such as population (prompts, medical records. difficult choices (within hospitals, design and testing. registers for reminders, care Record linkage. (genetic across geographical Iterative epidemiological pathways, The Universal screening) areas) development. Needs research. guidelines) Patient Indicator. - Information on - Palmtop technologies assessment, - Research into the - Clinical Databases and the web and/or (for information, for accessibility and impact or use of management tools population digital TV (public records) usability research. informatics tools (electronic health registers. information and - New mobile Multi-faceted suggests appropriate records, audit tools) - Achieving educational tools telephones expertise required. and cost-effective - Educational aids multiprofessional for specific clinical - Digital TV (for - Implementation ­ priorities for (guidelines, medical access. Technical groups) disseminating health Understanding policymakers. teaching) and ethical - Clinician-patient information & people and - Areas of cross-over - Electronic clinical issues. communication communicating with organizational (bioinformatics) communications - Data protection/ tools: patients) factors, system tools (referral, security issues 1. Remote: - The WWW and its acceptability, booking, discharge; - Patient access Clinical email and applications for health resistance to correspondence, and control web-based (issues: quality control, change. Use of clinical - Integration with messaging confidentiality, access) tailored email/second other services systems for - Virtual reality (remote/ implementation opinion, laboratory (social work, consultation, transcontinental strategies. test police) disease surgery) - Innovative methods requesting/results - Clinical coding monitoring, - Nanotechnology for mapping reporting, e-shared issues service-oriented - Intersection of functional and This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 17 What issues currently dominate eHealth? What emerging How does research How do What is going on in eHealth? technologies are inform eHealth? developments in likely to impact on eHealth inform health care? research? care) (terminologies) tasks bioinformatics and technology needs, - Electronic (appointment health informatics. place of systems in networks (disease- booking, the organization - specific clinical Healthcare prescription Knowledge networking Business reordering). management, systems) Management 2. Proximal: systems - - Billing and Shared decision approaches, Discipline/disease- tracking systems making tools, communication specific tools - Audit & quality informed consent networks models, (diabetes assessment aids organizational informatics) systems 3. Mixed: On-line development to map - Telemedicine screening tools pathways. applications (for (for depression) - Evaluation interprofessional and therapeutic Formative, as above, communication, interventions also: Outcome patient (cognitive assessment to communication and behaviour establish impact of remote therapy) new systems on consultation) - Access and clinical outcomes, - Subfields (nursing equity issues processes and costs & primary care (data protection informatics) issues, the Digital Divide) - Quality issues for health information on the net - "virtual" health communities Source: Adapted from Pagliari, et al. 2001. 3.1 Improving the functioning of health care systems Health systems are very complex. So too are the types of processes and information needs that are handled in health care systems. To be useful, information systems must capture and process data with broad diversity, scope, and level of detail. The nature of health care systems, particularly as regards information, is markedly different from most other sectors. In banking, for example, there are limited terms used, limited transaction possibilities, and simple information needed about customers, and well established standards for data exchange among banks so that most transactions can be performed at automated terminals by the customers themselves. The options for information systems within health care are much more complex due to the array of data types. For example, the automation of patient records must deal with a variety of data requirements and specification problems found in many health care data types which are exacerbated by the size and complexity of the medical vocabulary, the codification of biomedical findings, and the classification of health conditions and interventions. Nomenclature issues include concepts such as procedures, diagnoses, anatomical topography, diseases, aetiology, biological agents such as classification of micro-organisms, drugs, causes for health care contact, symptoms and signs, and many others. Possible combinations and detailing represent a staggering number of possible identifying coding requirements. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 18 Information systems within the health care system ­ patient records, tracking of disease prevalence, monitoring drug supplies, maintaining ordering systems for supplies, billing procedures ­ all stand to benefit from the use of ICTs. ICTs are the basis for the development and operation of information systems and enable the creation and application of knowledge. Information systems function at many levels of sophistication and complexity -- from very specific to very general. Example 1 gives three examples of information systems that have been developed in South Africa. One is stalled, one has been reasonably successful and the third failed completely, according to its evaluation team (Littlejohns, et al, 2003). All three examples illustrate the need to: · pay attention to past experience · involve users in the planning and design of the system · build information cultures · strengthen capacity of users · set realistic goals · focus on the benefits of the system, rather than the technology. Example 1: Developing health information systems in South Africa 1. A National Health Care Management Information System (NHC/MIS) was designed to cover medical records, patient registration, billing and scheduling modules in select hospitals in all 9 provinces. Most provinces have a minimum patient record. The National Health Information System Committee of South Africa (NHISSA) has prioritised the standardisation of the Electronic Health Record. The South African Department of Health (DoH) is working with the Home Affairs National ID System (HANIS) Project to incorporate its data elements onto a smart card being developed by the project. The information will include: a minimum patient record, which includes ID Verification; blood group; allergies; donor status; last 10 diagnoses, treatment, prescriptions; and medical aid. Reliance on the HANIS system is perhaps questionable, however, since it has been in the pipeline for a number of years without any meaningful progress. 2. The South African District Health Information System (DHIS) was launched in 1998 in all provinces. This was the first systematic data-gathering tool that could be used to identify public health issues. It enabled all the 4153 public clinics to collect information on 10 national health indicators. DHIS is facilitated by the Health Information Systems Programme (HISP). On completion of a three-year pilot project in the Western Cape the HISP model (comprising training methods, data handling processes and software tools) resulted in the development of a co- ordinated strategy following acceptance and endorsement as the national model by NHISSA in the latter half of 1999. The HISP approach to the development of a DHIS, is based on a six-step implementation model: Step 1 ­ establishment of district information teams, Step 2 ­ performance of an information audit of existing data handling processes, Step 3 ­ formulation of operational goals, indicators and targets, Step 4 ­ development of systems and structures to support data handling, Step 5 ­ capacity building of health care providers, and Step 6 ­ development of an information culture. The HISP model has been exported to other countries, including Mozambique and Cuba. 3. The South African province of Limpopo has 42 hospitals (2 mental health facilities, eight regional facilities and 32 district facilities). The area is one of the poorest in South Africa. The overall goal of the project was to make use of information systems to improve patient care, the management efficiency of hospitals and generally increase the quality of service. Among the functions of the proposed information systems were: master patient index and patient record tracking; admission, discharges and transfers; appointments ordering; departmental systems for laboratory, radiology, operating theatre, other clinical services, dietary services and laundry; financial management; management information and hospital performance indicators. Introduction of the systems ran well over time and budget and only became implemented in some of the hospitals. Major factors identified as leading to the failure of the implementation of this system which are likely to apply to other situations, included: failure to take into account the social and professional cultures of healthcare organisations and to recognise the need for education of users and computer staff underestimation of the complexity of routine clinical and managerial processes; different expectations among stakeholders; implementation of systems is often a long process in a sector where managerial change and corporate memory is short; failure of developers to identify and learn lessons from past projects. Source: Electronic Government, Issue 2, Vol. 1, 2004:31; www.hisp.org. South African Health Example, 5Review 2001, ftp://ftp.hst.org.za/pubs/sahr/2001/chapter6.pdf; Littlejohns, et al 2003. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 19 All three project examples were `big' projects ­ covering an entire province or across the country. A clear lesson about big information system projects is that they should actually start small ­ as pilots or prototypes, with careful monitoring and assessment to test out the challenges and issues that are likely to emerge. This is one of the major conclusions of a project to use telephones and the Internet to improve the administration of appointments for people attending the 168 first-level health care centres of the Social Security and Services for the State Workers Institute (ISSSTE) in Mexico (Rodriguez-Aleman, 2003). Careful planning, regular involvement of and communication with stakeholders and enabling local initiatives and adaptations to the overall plan all helped to increase ownership, acceptance and use of the system. In Bangladesh, a project with a different level of scale was developed to register, schedule and track immunisation of children. Based in the city of Rajashahi, a computerised system was introduced to replace a manual record keeping system (Ahmed, 2004). Over a period of three years, the new system was able to increase immunisation rates from around 40% to over 80%. A critical element of the success of this intervention was that it was designed to meet the interests and needs and provide tangible benefits to a number of different stakeholders. It reduced the time health workers spent searching records; it made it easier for managerial staff to supervise the immunisation system and monitor performance; it improved immunisation protection for children and ultimately their health, a positive benefit for the families reached by the system. Fundamental to effective use of ICTs is the concept of added value -- all participants must get out of an information system at least as much as they put in -- it must generate benefits greater than its own cost, otherwise the system becomes a burden. Information systems are almost totally dependent upon the staff that provide and record the information, yet these are usually the lowest valued and least involved. If there are no benefits evident to them for the contributions they make, there is a high probability of building inaccuracy, instability, and future failure. Learning about ICTs in health care systems implementation is that the context in which they operate, the clinical patterns they support, and the policy environment will all change constantly and the information systems must respond to these changes. As well, new opportunities will arise, which should be exploited when cost-benefit analysis shows this to be justified. Monitoring and evaluation of information systems and other ICT interventions enables adjustments to be made according to how the changes are perceived, and how they change practice. 3.1.1 Key lessons Key lessons in this brief review of the literature and analysis about the role and potential of ICTs in improving the functioning of health care systems are that: · an effective approach to setting up information systems is to explicitly identify the objectives of the system and determine the expected results · for maximum potential success an ICT project requires all participants (from the developers of the system to the users and beneficiaries) to view the innovation as adding value to existing systems; if the people using the system do not like, want or support it, it will likely fail · information systems should never become static or they lose their value. 3.2 Improving health care delivery Integrating the use of ICTs into existing health systems has helped to improve the delivery of health care in a number of ways (Rodrigues, 2000a, 2000b; PAHO, 2001). These include: This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 20 · the use of telemedicine to improve diagnosis and enhance patient care · improvements in the continuing professional development of health workers and better sharing of research findings · efforts to extend the reach and coverage of health care to make an impact on specific conditions. 3.2.1 Telemedicine Telemedicine is a growing field. According to the International Telecommunication Union (ITU, 2005), telemedicine is a powerful tool for improving health care delivery which as been successfully implemented in pilot projects in many countries. Appendix 2 includes reference to many of the studies reporting on the impact of telemedicine interventions. Many of these pilots clearly demonstrate proof of concept ­ telemedicine can improve diagnosis and treatment of specific conditions. Although telemedicine can be highly effective, a SIDA report (Greenberg, 2005) notes that cost is an issue: `in its high-tech implementations, it is unlikely to be cost-effective or affordable in widespread use. ... Those implementations requiring high bandwidth and sophisticated remote equipment have generally proven practical in cases where money is not an issue or as an alternative to high-cost air transportation and lodging.' Used wisely, however, telemedicine can be a cost-effective method that richer countries can employ to aid capacity building in the health care systems of poorer countries. (Johnson, et al. 2004). A study on the use of teleophthalmology found that the technology transfer was effective in reducing the burden of eye disease and that practitioners in South Africa also learned novel procedures that could help future patients and improve cost-effectiveness. Using teleconsultations has been assessed in a number of specialties (Campenella,et al, 2004). Some, such as laboratory, dermatology and cyto-pathology teleconsultations, are not time consuming and are reliable. The effectiveness and cost-benefit of teleconsultations in cardiology and radiology are disputable. Telemedicine piloting is well advanced in Latin America, with a number of case studies that contain learning that can be informative for scaling up projects. These include the use of distance education to encourage breastfeeding (de Ornes et al, 2002), the use of telemedicine in rural areas to improve maternal health (Martinez, 2005), and an exploration of how the Internet can be used in urban areas to contribute to the prevention of mental health (Finquelievich, 2000). In Africa, most people are rurally based and their health care is sparse. Yet the epicentre of health care expertise and resources in Africa remains in the cities. The result is that the people come to towns and cities for their health care in huge numbers and at enormous cost. ICTs are beginning to be used innovatively to bring the healthcare more effectively to the people. Telemedicine is one way this can be done, as the example from the Africa Medical and Research Foundation (AMREF) telemedicine project indicates (see Example 2). Example 2: AMREF: using telemedicine to improve rural health The African Medical and Research Foundation (AMREF) is improving its clinical outreach programme with the help of telemedicine. A number of sites have been set up to test the approach and gradually expand across nearly 80 rural hospitals currently served by AMREF across East Africa. The AMREF telemedicine project provides expert second opinion to clinicians in those hospitals supported by the AMREF outreach programme. The primary goal is to improve the quality of and access to specialist care. The secondary goal is to improve care through training using teleconsultation and CME courses. An AMREF clinician and consultant physicians consult on specific cases. Clinical staff from the rural hospital use email to forward the case notes and supporting images of the patients to be `seen' the following day. Notes may be scanned images of handwritten notes or PC-based using proprietary software. Digital images of the patient, digital images and/or video clips of any visible lesion, and digital images of X-rays can accompany the notes This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 21 together with the results of any other diagnostic procedures, The outreach clinic accesses the Internet for transmission of the clinical notes and attachments, and begins his virtual consultation. Consultants meet to prepare opinions and at an agreed time a teleconferencing connection will be established. On completion of the consultations, the entire record is saved on a dedicated library file on the AMREF server. In this way, AMREF helps link thousands more patients in remote areas every year with services and skills in an increasing number of hospitals in Eastern Africa. Source: www.amref.org The examples cited here and the experience elsewhere demonstrate that telemedicine helps countries deal with shortages of health care professionals through better coordination of resources, builds links between well-served and underserved areas of the country and helps link health workers to latest research and information and can enhance sharing of experience and professional development. ITU (2005) notes that telemedicine is more than the delivery of hardware and software. Incorporating already existing technology ­ such as phone or email ­ into medical practice and routine consultancies can make a difference. 3.2.2 E-learning In a key paper produced as part of a global review on access to health information, Godlee et al (2004) concluded that 'Universal access to information for health professionals is a prerequisite for meeting the Millennium Development Goals and achieving Health for All. However, despite the promises of the information revolution, and some successful initiatives, there is little if any evidence that the majority of health professionals in the developing world are any better informed than they were 10 years ago. Lack of access to information remains a major barrier to knowledge-based health care in developing countries' (as well as in many parts of the `developed' world). Using ICTs effectively offers the promise of changing this situation for health workers. One attempt to improve access to information has been undertaken by WHO and the United Nations Development Programme (UNDP) in India (see Example 3). Key lessons emerging from this project that are relevant to many other initiatives to increase access to basic health information include issues around connectivity, capacity and content. For example, · connectivity took longer to establish than anticipated · local capacity needed to be strengthened in terms of both project management and the use of ICTs · content and format of the information needed to be relevant to users' lives and needs, including available in local languages is vital to many community health workers. A major concern for this project was the need to ensure that already existing inequalities in health information access were not exacerbated by the introduction of ICTs. Project managers found that a strategic approach was needed to reach health workers less likely to have access to the internet and computers skills (women, lower ranked professionals). Example 3: Improving access to information in India The Health InterNetwork (HIN) India project (www.hin.org.in) was launched in 2000. This pilot project was designed to document and assess the impact of ICTs on the flow of reliable, timely, and relevant information for health services provision, policy making, and research and to evaluate and better understand the challenges of improving the flow of and access to relevant health information in developing countries. It worked with local organizations to ensure relevance and sustainability. The project introduced ICTs into seven primary health centres and three community health centres, and upgraded computers, internet connection, and networks in four research institutions and two medical colleges. A basic package consisted of a desktop computer, printer, scanner, electrical and telephone connection, and a subscription to an Internet service provider. Source: http://www.rho.org/html/ict_progexamples.htm#india In Nepal, the unique ability of radio to reach, entertain, and educate isolated, less educated, rural health workers and communities made it an ideal medium for attempting to improve the This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 22 quality of health services and support the continuing medical education of grassroots health workers (see Example 4). Radio reaches service providers living in isolated communities in difficult terrain and gives them a chance to receive standardised instruction in an appealing format. This initiative highlighted the importance of: · undertaking a comprehensive needs assessment · ensuring stakeholder involvement in the process · strategic planning. It also demonstrated that it is possible to combine an entertaining story with accurate and updated technical information, as the format used involved radio dramas. Another approach that can be used to reach out to those not usually included is through the electronic networking, undertaken by the Health and Development Networks (HDN ­ see Example 5). Electronic networking is a valid and viable means of providing learning, dialogue and highlighting issues as well as creating virtual conferences among those who cannot attend in person, at a fraction of the cost of conventional meetings. These forums can, and do, effectively attract participation from people in developing countries, despite issues of electronic connectivity and access. The key skills required are good facilitation and moderation skills. The content exists, and is shared on a daily basis at exclusive events, meetings and workshops. Electronic processes can bring this content out into broader forums, so that it can have an influence on daily practices as well as wider audiences, such as policy-makers and international organisations. Health workers involved in primary health care in developing countries are often isolated. They work in remote settings, often alone, and have little or no access to up to date information and opportunities to exchange experience with colleagues. Making use of new technologies and better use of existing technologies is beginning to improve this situation. In Ghana, Kenya and Uganda, Satellife has been building experience around the use of personal digital assistants (PDAs) ­ small handheld devices that enable health workers in remote settings to gain access to information, capture, store and share important health data, and link to the experience of other colleagues to improve their practice and the outcomes for their patients. Example 6 summarises some of this experience. Example 4: Distance education radio for health workers in Nepal The Radio Communication Project (RCP) used two radio drama serials and several reinforcing components. `Service Brings Reward' was an entertainment distance education programme aimed primarily at 15,000 grassroots health workers. `Cut Your Coat According to Your Cloth' was aimed at the general public to improve public perception of health service providers and increase demand for services. These programmes followed a mutually reinforcing approach by simultaneously increasing provider skills and client demand for services. The technical content of the distance education serial was based on the Nepal Medical Standards guide. Reinforcing components included print materials (programme guide, reference manual, posters, wall hangings, calendars, method-specific brochures and flipcharts) and Interpersonal Communication and Counselling training. The RCP incorporated messages about the well-planned family, conception and contraception, modern contraceptive methods, the role of the caring husband, communication and counselling, maternal and child health, HIV/AIDS, immunization, and adolescent reproductive health. A guiding principle of the RCP was message consistency across the various communication channels and audiences. A systematic and participatory process was used to ensure that appropriate, accurate and consistent content was incorporated into both radio drama serials, as well as the interpersonal communication and counselling and print components. All the stakeholders (government, INGOs, NGOs, technical experts, writers, producers and audience members) met together to produce the design document which spelled out in detail the content of each radio programme episode, responsibilities for different aspects of the project, a production and implementation schedule and an evaluation strategy. Source: Adapted from a case study by Diane Summers in Ballantyne, 2002 Example 5: Electronic networking and communication support on HIV and AIDS Home and Community Care (HCC) plays a vital role in providing acceptable, essential, quality care and support to people with HIV and AIDS. Limited attention has been given to HCC in the past at all levels - especially in international discourses. Grassroots workers seldom have a voice at the international level - thus expertise and This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 23 lessons learnt in the field are seldom shared. While international conferences provide opportunities to share lessons, there is often little continuity between them, and the discussion is limited to the few able to attend such events. The Insight Initiative project provided electronic networking and communication support to two regional events, spanning two continents: southern Africa and Asia and the Pacific. This project used electronic networking as a means to increase the number of voices and perspectives in the preparation and follow-up to the two events, and to facilitate exchange of relevant content between the southern Africa and Asia Pacific regions. The aim was to ensure that as many voices as possible were heard and have the opportunity to participate in the conference, especially those who cannot attend in person. Two specific time-limited moderated structured discussions related to the conferences (2 and 7 months respectively) were held using the ProCAARE e-mail discussion forum. (ProCAARE is a discussion forum managed by SATELLIFE, the Harvard AIDS Institute, and Health & Development Networks.) A new theme was introduced every month. The moderation team introduced each new theme with a set of clearly designed questions, aimed to guide and focus the discussions. In addition, 26 Key Correspondents from Asia, Africa, Latin America and Eastern Europe were recruited to write articles that fed into the conference discussions as well as provide session coverage from the actual events. During the conferences the team worked intensively to provide critical analysis on the presentations they heard as well as talking to participants to get their views on what was presented. Following the events, post-conference structured discussions were facilitated where the conference coverage, local content and emerging issues around HCC were discussed and evaluated and put forward for further attention. Continuity was facilitated between the two events. Using innovative methods including deliberative dialogue to stimulate and engage people, the active participation in the discussion was unprecedented in HDN's experience, as illustrated by its extensive regional coverage, including contributions from Asia, Africa, Latin America and the US and its generation of a wide range of content and views from communal, institutional and individual perspectives. Participation increased from 700 to just under 2500 over 6 months. Source: Adapted from a case study by Tim France in Ballantyne, 2002 Example 6: Using PDAs in Africa ­ Satellife's experience In Ghana, community volunteers have been using PDAs to collect data as part of a measles vaccination programme. In Kenya, medical students were equipped with PDAs loaded with relevant information about their studies in obstetrics/gynaecology, internal medicine and paediatrics. In Uganda, practicing physicians were given PDAs containing basic reference material as part of their continuing medical education. The Ghana project yielded compelling evidence of the value of PDAs for data collection and reporting. Data from 2400 field surveys were submitted to the implementing agency by mid-day following a vaccination campaign in a particular location. They were analysed and a report prepared for the Ministry of Health by the end of the day. Previously, data entry also would have taken 40 hours using paper and pencil surveys. The Kenya and Uganda pilots demonstrated the value of using PDAs for information dissemination. In Uganda, 95 per cent of physicians reported that using the reference materials over a three month period improved their ability to treat patients effectively. This included improvements in diagnosis, drug selection and overall treatment. In Kenya, the majority of students actively used the treatment guidelines and referred to the medical references and textbooks stored on the PDA during their clinical practice. Source: Satellife, 2005 Another use of technology in Uganda has had an impact on maternal mortality. The Rural Extended Services and Care for Ultimate Emergency Relief (RESCUER) pilot project in eastern Uganda made use of a VHF radio and mobile walkie talkies to help empower a network of traditional birth attendants, to partner with the public health service centres to deliver health care to pregnant women. This resulted in increased and timelier patient referrals as well as the delivery of health care to a larger number of pregnant women (Musoke, 2001). It also led to a reduction in maternal mortality from 500 per 100,000 in 1996 to 271 in 1999. Two strong messages that come through in the experience highlighted in this section are the need to ensure that ICT use in the health sector reaches out to the poorest populations and that there is a strong focus on linking rural, remote, difficult environments that are underserved with the resources that are located in the central health services. Danida (2005) ­ and others ­ argue that ensuring that people living in rural areas are the major beneficiaries in ICT initiatives will help meet the Millennium Development Goals (MDGs) including those related to health. However, a recent FAO (2003) report points out This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 24 that `there has been virtually no progress in making the internet available in the least developed countries, especially in the rural areas'. By including the rural population in the group of beneficiaries of ICT initiatives in the health sector, more MDGs will be addressed, as the rural poor constitute the most vulnerable population group. Of one billion people living in extreme poverty, 75 per cent live in rural areas. Health conditions in rural areas are generally poorer, and access to information, services and supplies is most limited. Implementing this probably means encouraging intermediaries such as NGOs, health educators, academic institutions or local entrepreneurs to act as a conduit for information available via technologies such as the Internet, and the poor, through translation, adaptation and use of more traditional means of communication. 3.2.3 Key Lessons Key lessons in this brief review of the literature and analysis about the role and potential of ICTs in health care delivery are that: · Telemedicine provides benefits of resource coordination, urban/rural linkages and connecting remote health staff to centralized health expertise and resources. · Incorporating already existing technology ­ such as phone or email ­ into medical practice and routine consultancies can make a significant difference. · While there is still limited evidence of improved access to learning in the developing world, there is strong potential for e-learning in health as demonstrated by a variety of successful small projects around the world. · Multiple ICT routes can, and are, being used for e-learning in a mixed toolbox approach (for example: including internet, radio, SMS, PDAs and combining with print). 3.3 Improving communication around health People take on board new information, new ideas, new approaches by making sense of it in terms of their own local context, their own social, economic and cultural processes and assimilate it, adapt it and incorporate it into their daily realities in ways that help them better deal the local situation. ICTs present a range of opportunities for the delivery of health information to the public, and for developing greater personal and collective communication. Commentators view ICTs as also representing a way for health workers to share information on changes in disease prevalence and to develop effective responses. And they provide opportunities to encourage dialogue, debate and social mobilisation around a key public health concern. However access remains an abiding issue is access, particularly in developing countries (Shilderman, 2002). Approaches that are being used for any of these purposes include: · developing of Internet information portals · using mass media to broadcast widely · developing interactive programming on broadcast media. · making more effective use of existing communication systems · developing community access points (CAPs). 3.3.1 Information via the internet and other ICT media ICTs are presenting health communicators, media and other stakeholders with a range of new and stronger opportunities for health information dissemination. Whether this dissemination is effective or not requires further analysis, but the actual mechanisms for distributing health information and debate have clearly been expanded by the advent of ICTs. Information and communication via the Internet This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 25 There are increasing numbers of health-focused portals and information sites aimed at providing information to consumers as well as sites dedicated to health workers, to individuals and to a range of communities of interest in health. Patient focused Navigating these information sites and determining which are worthwhile is becoming an increasing challenge for patients and health workers alike. A systematic review of "web- based therapies" intended to encourage an individual's behaviour change found that 16 of 17 studies revealed the outcomes of improved knowledge and/or improved behavioural outcomes for participants using web-based interventions (Wantland, 2004). Outcomes included increased exercise time, knowledge of nutritional status, slower health decline. Bessell and her colleagues (2002) concluded from another systematic review that there were some positive effects on health outcomes from the use of information sites on the Internet, however, much of this was based on anecdotes and opinion rather than well-designed controlled studies. Schloman (2002) concluded that because of the amount of information and the immediacy of access to it (for those with connectivity), the issue of quality of information was important. She highlighted several rating systems that had been used but identified methodological problems with many of the approaches. She suggests that health workers have an important role to play in educating patients to be critical users of the information they find on the Internet. Godlee and her colleagues (2004) make the point that health workers too `need critical appraisal skills to be able to distinguish unreliable from reliable sources of information'. General focus There are a growing number of sites and portals that are direct at general public audiences or at particular groups of users, such as people living with HIV and AIDS, or media who want background information and data for health reporting. Many international NGOs have recognised the potential of the online sphere for extending traditional communication projects, as well as for developing new approaches; such as providing resources for communications online. There is a need for policy makers to share learning and to collaborate around HIV and AIDS communication e-resourcing in order to maximise this avenue of media support. Information and communication via the ICT enabled media ICTs can also be used to raise awareness of an issue, to develop dialogue within a community, to increase demand for services, and to encourage people to seek support and accurate information as the experience of a group (Puntos de Encuentro ­ Meeting Points) in Nicaragua (see Example 7) demonstrates. The group made use of TV, radio, print and oral communication techniques to generate grater understanding about HIV and AIDS. This echoes the experience of the type of health promotion work done by agencies such as Soul City in South Africa (see http://www.soulcity.org.za , or Health Unlimited in Rwanda and Cambodia (see: http://www.healthcomms.org/comms/integ/ld-radio-oct05.html). In all of these cases, there was reinforcement and deepening of the issues; the emotional identification created through the characters, the building of alliances and local skilll-building, in order to achieve a longer lasting impact. A key lesson emerging was the time it takes to do this effectively and the recognition that it is never a straightforward process, but a set of successive steps towards the point. The process of assimilating new information takes time. Exploring issues in depth and detail rather than changing themes constantly allows people the time to engage with the information and internalise it. Example 7: Multi-media health promotion in Nicaragua Somos Diferentes, Somos Iguales (We're Different, We're Equal) is a multi-media/multi-method strategy that promotes the individual and collective empowerment of Nicaraguan young people to defend and exercise their This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 26 human rights in daily life. The centre of the strategy is a TV series, Sexto Sentido. This is complemented by a daily youth talk radio show, and combined with interpersonal and community reinforcement, through alliances with over 200 organisations around the country, face-to-face capacity building activities with grassroots youth leaders and local journalists, a methodological manual for workshops with young people, distribution of educational resource packs for use by local groups, help in setting up of peer-led support/discussion groups, alliances with over 70 local TV and radio stations to expand coverage and debate, periodic thematic campaigns organised and carried out in conjunction with hundreds of local organisations, service providers and media outlets all over the country, and ongoing monitoring and evaluation and dissemination of the results. Source: Adapted from a case study by Humberto Abaunza Gutiérrez in Ballantyne, 2002 3.3.2 Increasing effectiveness of communication systems ICTs such as Geographical Information Systems (GIS) can facilitate health sector planning, as well as helping to predict and identify the spread of emerging disease conditions. In Bangladesh, for example, GIS data has been used to warn the health authorities about the likely location and spread of cholera in coastal areas. In India, the Malaria Research Centre in New Delhi has used images from India's remote sensing satellites to map areas where a malaria-carrying mosquito was likely to be found on the basis of ecological factors conducive to its breeding and survival. Their model correctly predicted exact breeding locations, which were then targeted for specific control measures. An estimated 50 million inhabitants were at risk from this mosquito, whose presence was in some cases unknown to the health authorities until the satellite aided study was carried out (Anon, 2005). Also in India, the private company, Voxiva, has been working with health authorities to make use of existing communication systems to develop more effective surveillance information in the aftermath of the 2004 tsunami. Example 8: Developing quick responses in India In Tamil Nadu state, a Health Watch programme was launched in May 2005 that allows health workers, even in remote areas, to immediately report disease incidence data to health officials. In turn, health managers can quickly analyse information about suspected cases, share technical information and resources, and initiate an informed response. By linking Primary Health Centres with district health experts and programme managers, activities can be coordinated more effectively and resources (supplies, technical personnel, and transport) can be allocated more efficiently. During the implementation, Voxiva trained more than 300 doctors from Primary Health Centres using simple, easy to use bilingual manuals and interactive sessions. The training sessions were coordinated with the state to reinforce disease surveillance guidelines and outbreak response protocols. The phone- and web- based data collection and communication system strengthens Tamil Nadu's disease surveillance capabilities at the district and sub-district levels. The approach makes use of existing communications infrastructure: mobile phones, fixed line, and the Internet. Source: Voxiva, 2005b In Africa, the Uganda Health Information Network (UHIN) has been making use of personal digital assistants (PDAs) to provide early warning information about the spread of communicable diseases such as measles or cholera, as the following example describes. Example 9: Preventing illness in Uganda Veronica is a midwife in the Rakai District in southern Uganda. She uses her PDA for her work and for her community. She travels to the wireless router that stores the surveillance report for the entire district and where she uploads reports from the rural health clinic where she works. She also can download news and medical information. If there is an outbreak of measles somewhere in the district, she will learn of it before it reaches her community. She can advise people how to prevent catching it. Equally, if her report shows a local rise in cholera, the district will review her data and send medications and specialist assistance to help out. It used to take six months before the district would respond to this type of distress message, if at all. The data collection aspect of this initiative was particularly successful. The overall process was four times as effective as manual data entry. Even with the costs of hardware and software, it was still 25 per cent more effective. Source: Rich Fuchs, Satellife, 2005; Greenberg, 2004 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 27 3.3.3 Greater access to communication tools and opportunities A third and highly significant area where ICTs are being used is for improving communication around health centres on community access. Developing a range of new ways for people to access health information and also to communicate themselves about health due to having access to communication mediums is a vital area of ICT strategy. Community access points Research in Zambia, Botswana and Mozambique found that access to information about HIV and AIDS was a major concern (Geers and Page, 2005). Recognising that it was not possible to provide individual access to such information, the study recommended developing community access points (CAPs) which could act as HIV and AIDS `knowledge centres', telecentres and local service providers. Encouraging uptake of the services could be facilitated by either basing or placing such centres close to primary client organisations ­ those who were likely to make extensive use of the service ­ such as the media, schools and health clinics. Community telephones Another form of community access comes from the example in Bangladesh of how the introduction of village level mobile phones as a way to increase household income has led to improvements in food security, and investment in health and education (see Example 10). While not directly targeted at the health sector, it demonstrates the way an integrated approach to using ICTs can contribute to the achievement of several MDGs ­ reduction of poverty and hunger, access to basic education, improvement in child health ­ at the same time. Similarly, reducing illness can have a very direct impact on livelihoods. Every day that is not spent being ill or taking care of a child sick with a recurring disease such as malaria can be used productively (Greenberg, 2005). Identifying ICT programmes that can have impact in different sectors or deal with multiple determinants of health are likely to be more effective. Example 10: Creative use of phones in Bangladesh and Uganda In rural villages in Bangladesh where no telecommunications service has previously existed, Grameen's Village Phone programme provided mobile phones to very poor women who use the phone to operate as a business. The benefits to both the operator and the community have been tremendous. The typical "village phone lady" has an average income three times the national average. A Canadian International Development Agency (CIDA) commissioned study1 concluded that the Grameen Village Phone program yields "significant positive social and economic impacts, including relatively large consumer surplus and immeasurable quality of life benefits". Users of the phones can save from 3 to 10% of their household income from gaining better prices for the sale of goods or from refraining from unnecessary trips to the urban areas. The income that Village Phone Operators derive from the Village Phone is about 24% of the household income on average ­ in some cases it was as high as 40% of the household income. The increase in household income meant improved food security, a greater ability to invest in health, education and clothes for children and in an increased propensity to save. The lessons from this programme are now being applied in Uganda, where an initiative is underway to provide rural communities with communication services to enable them to break out of the cycle of poverty. Agreement was reached between the Grameen Foundation USA, MTN Uganda (the country's leading mobile telecommunications provider) and its public access partnership, together with a number of microfinance organisations. From the successful pilot programme in 2003, an independent company, MTN VillagePhone was formally created and has been successfully extending its operations. Lessons that are emerging include: all parties should benefit; microfinance sector is a channel to market; the telecommunications provider should provide wholesale airtime to VillagePhone operators in-country staff should manage the business. Source: 1 Grameen Telecom's Village Phone Programme in Rural Bangladesh: a Multi Media Case Study. Canadian International Development Agency, March 2000. Keogh and Wood, 2005 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 28 3.3.4 Increasing interaction, participation and amplifying `voices' ICTs are being seen as presenting new opportunities for the voices of those who are not usually consulted - particularly those who are affected by ill health - to be heard and for that local knowledge to be used to help frame and develop better services and better responses to people's illness. Ownership of communication Most of the studies highlighted in this paper are owned primarily by experts, rather than the beneficiary communities. They rarely suggest any consideration from stakeholders about what they think of the studies and whether they reflect their needs. ICTs present new innovative ways for the local voice to be amplified. New opportunities ICT has resulted in innovative and new communication forms. There is more peer to peer communication between individuals, as well as between intermediaries such as media or health workers. There is more scope for personal reflective communication, anonymous online communication and research and online community networking by communities of interest as well as the traditional communities as defined by geography or social character. For example HIV and AIDS provides many illustrative examples of new communication enabled by ICTs; e-forums and news groups abound, as do websites by both health service providers and health communicators, advocates, international and local groups and many others. Increased two way communication via radio Increasingly, programme planners are being advised to make use of application designs that encourage long-term interactive dialogue, rather than one-time broadcast of information (Maxfield, 2004) and approaches that make use of more than one particular technology. Radio remains a central medium for health education, health promotion and participatory health communication in developing countries. A major future trend is the convergence of radio with internet based communications. Newer ICTs add to radio the potential to develop a stronger feedback loop, with listeners engaging with the broadcasters in a range of new innovative ways, such as through increased phone-ins due to mobile telephony, through email and other internet based communication. Case studies of interactive radio instruction (IRI) in the Dominican Republic, Zambia, and Guinea show that this use of a previously one-way technology can effectively reach hard-to-reach populations and result in high learning gains and decreased inequality (Bosch 2002). Increased local expression about health can include people talking about health issues on the radio via mobiles or via submitting emails. ICTs present opportunities for expressing opinion and networking locally and globally about health advocacy issues, and opportunities for personal expression via blogs, email and in chat rooms and eforums. While many aspects of ICT impact are still strongly western in nature this aspect of personal and community expression is gaining ground in the developing world, where internet cafes and mobile telephony present improved access opportunities, and where the ICT-enabled communication is not predicated on expensive equipment, knowledge or social position. There is a democratizing aspect of the open unmediated communication that ICTs offer. There is a growing body of anecdotal examples of audience engagement via radio; internet/email and mobile do provide compelling evidence that ICTs are certainly increasing the opportunities for such expression. Whether this translates to impact on policy or social structures is another debate. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 29 3.3.5 Key Lessons Key lessons about the role and potential of ICTs in improving communication around health include that: · there is growing evidence that ICTs aid health information dissemination, particularly via online routes · there is growing evidence that ICTs increase the effectiveness of some communication systems · through the provision of increased communication access, more people are `linked in' to communication opportunities · mass media ICTs, such as radio, remain key in communicating about health · there are demonstrable benefits in combining technologies, particularly some of the older with some of the newer ICTs · health information via the media should not be hurried unnecessarily as it is still constrained by traditional constraints of communication strategies This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 30 4. Constraints and challenges A number of factors can inhibit the introduction and successful application of ICTs in the health sector in developing countries. Satellife (2005) identified three main categories as connectivity, content and capacity. Madanmohan Rao (2005) adds five more categories for analysis: community, commerce, culture, cooperation and capital. 4.1 Connectivity With connectivity there are issues such as the lack of an enabling telecom policy and regulatory environment; access to electricity, solar power options, UPS back-ups, insufficient infrastructure, connectivity access and high costs. Embedded in this are issues around broadcasting rights and regulations controlling the media. Connectivity access ­ measured in terms of telephone access, personal computer ownership, and Internet connectivity ­ varies widely around the world, as indicated in Table 3. Inequitable access also exists within societies. Within developing countries segments of the population have been by-passed by the products of the information revolution. This is complicated by the fast-changing deployment of new technologies and accompanying standards that constantly raise the level of advancement that must be met by anyone who wants to remain current (Ishaq, 2001; Alcántara, 2001). This is part of much broader constraints that include insufficient telecommunications infrastructure, high telecommunications tariffs, inappropriate or weak policies, organisational inefficiency, lack of locally created content, and uneven ability to derive economic and social benefits from information-intensive activities (DOT Force, 2001; ECLAC 2000; Chandrasekhar and Ghosh, 2001). Table 3: Connectivity access 2004 Main Personal Internet Internet Telephone Computers Users per Hosts per Countries Lines per per 100 100 10,000 100 Persons Persons Persons Persons WORLD 19.0 12.9 13.6 422.2 Africa 3.1 1.7 2.6 4.9 Americas 33.9 34.5 30.9 2347.6 Asia 14.3 6.35 8.1 74.3 Europe 40.9 28.5 31.1 362.6 Oceania 43.4 50.7 47.9 1408.3 Source: International Telecommunication Union, World Telecom Indicators 2004 In the health sector, development and digital divides between industrialised and developing countries are wider than the gap observed in other productive and social sectors. In some cases, the changes brought about by the privatisation of healthcare added to the already high degree of structural inequity that prevails in most low and middle-income countries. Dependable connectivity is needed for reliable transactions. In developing countries fast connectivity is still limited and usually only dial-up access is available. Poor telecommunications infrastructure, limited number of Internet Service Providers (ISP), lack of access to international bandwidth, and affordable Internet access costs continue to be This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 31 barriers to widespread use of ICTs. National expenditures among countries, even for countries of comparable income level, vary considerably (Casas, 2001). Low per capita expenditure in health limits the market for new and expensive technologies. Per capita expenditure in ICT is a better indicator of the real level of ICT investment than expenditure as percentage of the Gross Domestic Product. Some developing countries have expenditures that are comparable to that of developed countries when expressed as percentage of the GDP, although the absolute value per capita is low -- for instance, relative to GNP Brazil has the same level of expenditures as Canada, although in absolute value Brazil invests 6.6 times less than Canada in ICT (World Bank, 2002). 4.2 Content Content factors include the lack of local content creation, the language used and the relevance of content to the local situation. Appropriate language is frequently neglected in ICT programmes and little content is available in local languages for health programmes. Another major content issue is the quality and reliability of health information. The Internet can provide a wide range of users with timely, accurate, diverse and detailed health information. However, its decentralised structure, global reach, levelling of access to the tools of publication, immediacy of response, and ability to facilitate free-ranging interchange also make the Internet a channel for potential misinformation, concealed bias, covert self- dealing, and evasion of legitimate regulation. It is very difficult to ascertain and recommend on the credibility, motives, sponsorship, and eventual conflicts of interest in the more than 50,000 health websites in existence. Many health public-oriented websites are profit-driven, others promote unproven and even dangerous forms of treatment or products, while others may be good intentioned, but contain misleading or false information (Rodrigues, 2000c; CHCF, 2000, 2001; Berland, 2001; Risk and Dzenowagis, 2001). Given the sensitive nature of health care information, and the high degree of dependence of health professionals on trustworthy records, the issues of reliability (data residing in the electronic health record are accurate and remains accurate), security (owner and users of the electronic health record can control data transmission and storage), and privacy (subject of data can control their use and dissemination) are of particular significance and must be clearly and effectively addressed by health and health-related organisations and professionals (Ramsaroop, et al. 2003). Reliability, security, and privacy are accomplished by the implementation of a number of preventive and protective policies, tools, and actions that address the areas of physical protection, data integrity, access to information resources, and protection against unauthorised disclosure of information. A comprehensive review and reference source on personal data protection regulation was published by the Pan American Health Organization (Rodrigues, Wilson and Schanz, 2001). The experience of supporting the development of appropriate health information in East and Southern Africa (see Example 11) illustrates a number of issues around developing effective and relevant content. It makes the point that creating and sharing local content is a huge responsibility and increasingly demanding and complex. To achieve results, more investment is needed in terms of time, facilities, staff, training, and more support and stronger commitment is required from governments and donors. This particular approach made use of existing national information centres and tried to strengthen them through building capacity and introducing more effective collection of information processes and searchable electronic databases. The most active centres had a technical person who championed the activities of the centre and provided leadership, vision, motivation, support and guidance. However, This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 32 when adding work to an existing centre that already has a full complement of activities, results take longer to achieve. The greatest challenge facing any dissemination activity is the need to repackage information differently for various audiences. These skills are critical, yet scarce. Moreover, repackaging information takes valuable resources that are often unavailable. Content experts or a team of experts are required to identify what research needs to be repackaged. Often both technical content experts and information and communication specialists need to be trained to repackage material, and be enabled to work together to both build a strong evidence base, but also help to make it more accessible to policy makers, health workers and the public. Example 11: Health information dissemination centres in East and Southern Africa Promotion of health policy and programmatic changes requires access to current research findings, prepared in formats that are easy to use. A project to strengthen the capacity of institutions in East and Southern Africa to collect, collates, and distribute relevant health and nutrition information in a timely manner and increase information access at the policy and programme levels was undertaken by the Commonwealth Regional Health Community Secretariat (CRHCS) and the Support for Analysis and Research in Africa (SARA) project. A joint CRHCS/SARA assessment identified existing institutions to serve as information dissemination centres (IDCs).The role of these country IDCs was to disseminate regional information, collect country-specific information and grey literature and to conduct greater outreach to ensure that policy makers and programme managers had access to the information. Dissemination centre coordinators gathered existing research from institutions around the country on reproductive health and nutrition. Most centres collected research studies and wrote annotations that were produced as an annotated bibliography. In some areas, these were stored on searchable databases. As research was identified that could have wide impact ­ a study on the consequences of unsafe abortion was one example ­ computer-mediated presentations were developed together with short and targeted printed summaries, to share findings at regional, national and district level workshops and conferences. In Zimbabwe, a local theatre company developed a play about the findings to share with a number of different audiences. Key lessons from the experience include: information needs to be in the appropriate format to be valuable and used by various audiences; the more different formats and different channels that are used to share the information, the more likely it will be used; content experts and information experts need to collaborate to determine who the key target audiences are, what the best formats and delivery channels are to reach these audiences, and share the information in as many different ways as possible. Adapted from a case study by Renuka Bery in Balantyne, 2002 4.3 Capacity While capacity to adapt information to ensure that it is culturally appropriate and relevant is a major challenge, so too is the capacity to use ICTs effectively, to service and maintain them. A skilled ICT work force is an essential ingredient for the effective use of ICTs in health. Systems professionals and technology products and services providers and project team leaders with high skill levels and experience in working in the sector introducing the ICTs are important components of success. The number of technicians, scientists, and portion of the GNP devoted to research and development is a good indicator of those capabilities. Although the statistics in Table 4 are now a little dated, the trend and pattern they indicate demonstrate the regional variances in capacity, something that still needs to be addressed in today's society. The most successful efforts to incorporate information and communication technologies have occurred in countries with strong and efficient government and academic institutions committed to invest in education, scientific and technological development, and public services, in tandem with business sectors (for instance, banking and retail commerce) ready and willing to automate their operations. Table 4: Selected Technology Inputs by Region (1992-1997) GNP R&D as Technicians Scientists Region per capita US$ % of GDP per per 106 106 This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 33 Population Populatio n OECD Countries 20,113 1.8 1,326.1 2,649.1 Eastern Europe & 4,027 0.9 577.2 1,841.3 FSR East Asia 6,270 0.8 235.8 1,026.0 Latin America & 5,635 0.5 205.4 656.6 Caribbean Middle East 8,941 0.4 177.8 521.0 Sub-Saharan 1,971 0.2 76.1 324.3 Africa South Asia 1,764 0.8 59.5 161.0 Source: Rodríguez F and Wilson E , InfoDev World Bank 2000, modified Capacity also refers to inequities in societies and the sharing of resources within the community. For example, due to lower rates of literacy, women (and marginalised groups in general) are not given equal access to the benefits of ICTs. Ensuring that women are part of the target group, that gender deliberations have been undertaken by choice of the ICT tool, and that language or cultural norms do not exclude women benefiting from the ICT intervention are important considerations (Danida, 2005). Several recent reports have provided highlights on the use of ICT to combat HIV and AIDS. In November 2001, a consultant for the International Development Research Council produced a comprehensive report showcasing several pilot project activities in this area (Driscoll, 2001). Among other conclusions, the author recommended the importance of teaching girls and young women how to use the Internet. Other evidence (Mar Gadio, 2001) also suggests that women with the mastery of almost any level of ICTs increase their self- esteem and has spill over effects into other activities that work toward poverty alleviation, an important element in decreasing their susceptibility to economic situations which put them at greater risk of catching HIV and AIDS. The Mangelete women group in Kibwezi, who started the first community radio in Kenya, for example, has trained rural women in the production and use of video to generate income, disseminate new skills and use Internet to access the necessary information (Anon, 2002). 4.4 Community The question to be addressed here is who is using ICTs? What are the communities of users and what services exist to facilitate use and to encourage those who have not been involved in health dialogues previously? An important approach to the design and implementation of any ICT and health programme is to identify the various stakeholders who need to be involved and find mechanisms for including their perspectives and concerns and to find ways to mobilise their skills, expertise and resources. 4.5 Commerce New technologies have made it possible to open up trade in medicines and services via the Internet. This has both positive and negative consequences. One of the key factors to consider here is the degree to which it is possible to develop effective national or domestic Internet economies that promote online transactional capabilities that will be beneficial for consumers, for businesses and for public health interests. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 34 4.6 Culture Cultural issues need to be addressed in terms of appropriate and relevant content. Another aspect of culture is the need to examine and challenge the cultural inhibitions and barriers within society and institutions that prevent effective use of ICTs. This includes a commitment to transform the rules and regulations surrounding telecommunication and broadcast systems. It also means increasing political will to ensure that government procedures are more transparent and that information sharing cultures are encouraged. 4.7 Cooperation The use of ICTs for health and development involves local, regional and international participants as stakeholders. No one sector or one set of stakeholders can deal with the complexity involved in the effective use of ICTs in health. Technical knowledge, experience, and financial investments needed to establish large and complex ICT initiatives require tapping into resources and expertise that no single organisation retains. Several key groups should be considered when discussing efforts for ICTs and health. Dzenowagis (2005) identifies six major groups: · Citizens (including patients) · Professionals · Hospitals and academia · Health-related businesses · Governments · International agencies. Each of these could be broken down further. For example, the OECD (2005) has catalogued the activities of the major international agencies with an interest in ICT programmes for development. Within each grouping, there may also be those with a health focus, those with a technology focus, or those who are most concerned with development issues. They often have different perspectives on the aims and objectives of introducing ICT into healthcare and hold different views on potential barriers to implementation. The successful implementation of ICT and health programmes requires complex balancing of the competing views and concerns of the different stakeholders. Some clinicians will view new technology with suspicion, fearing its challenge to their professional autonomy and status. Patients will often seize on the potential benefits (particularly in making care accessible where care would otherwise not be available) but will also hold legitimate concerns about the security and confidentiality of any electronically held patient data. IT specialists may seek to use cutting edge technology where existing tried and tested technology would be more than adequate to deliver real improvements in patient care. Policy makers may require convincing that the initial investment costs in the new technology will bring the benefits promised. All these differing views and concerns need to be addressed at the outset of any intervention involving ICTs. Successful stakeholder engagement is not easy. People with the greatest health need are often those that prove to be the most difficult with whom to engage. If new technology is to meet their health needs, then carefully developed engagement strategies need to be developed. Crucially engagement needs to start at the beginning of an intervention; otherwise there is a risk of developing technical solutions looking for a problem to solve: health need and the views of the communities to be served must drive the ICT initiative. The effective participation of a large number of stakeholders needs to be coordinated by the public sector. So too does the development of policy frameworks to guide the use of ICTs. Absence of a national policy framework around ICTs and health is a further challenge and obstacle to achieving the successful introduction of ICTs into health programmes (WHO, This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 35 2004). Even where policies and strategies exist, technology developers, suppliers, users, and decision-makers must be aware of them and the effect they may have on their judgment regarding the acquisition, development, deployment, and operation of health ICTs. Policies must, necessarily, be in consonance with any overall informatics policies in force in a country as well as with its overall health sector policies. The national health ICT policies, in turn, set limits to any policies that may be established lower in the hierarchy, at regional or local levels. Once formulated, they must be implemented in a coordinated manner. The goal of establishing national strategies for ICTs is to provide a coherent national arrangement directed to facilitating projects, infrastructure development, maximizing the benefits for invested financial resources, and enabling people to function more effectively. Successful engagement with health workers is also crucial to the integration of ICTs in healthcare. ICT can be very challenging to the autonomy and professional status of health workers. The challenge arises from the ability for ICT to fundamentally change the way care is delivered, changing working practices, enabling different skill mixes in clinical teams, empowering different clinicians to make decisions about patient care, and empowering patients to self care. Clarifying the distinct roles for different stakeholders is important in ensuring that their efforts are complementary (Panos, 2005). For example, the international donor community plays a role in coordinating funding of ICT and health programmes; national governments should focus on establishing a clear regulatory framework, promoting equal participation of stakeholders and coordinating implementation; civil society organisations, the private sector, academic institutions and health system institutions are likely to lead on implementation and in monitoring, evaluating and learning from experience; grassroots organisations and local government have a role to play in identifying needs. 4.8 Capital Generally, there is little investment in ICTs for health even in most developing countries. The picture is one of fragmentation, with many different varieties of ICTs being acquired from different donors. Very few government-run health services have properly functioning ICTs within them, and there is no reliable infrastructure to enable inter-organizational transfers of information. Invariably, there is no national health information and IT infrastructure to underpin the delivery of health care. WHO (2004) makes the point that technologies must be `integrated into health services that meet basic needs' if they are to be considered to be essential investments. In East Asia for example, investment in ICTs for health is less advanced that might be expected, due to institutional, cultural and financial factors (Holiday and Tam, 2004). The financial factor is one that is common to other regions: effective use of ICTs in health will need resourcing at a higher level than is currently the case. Finding ways to blend private and public resources in ways that contribute to the development of improved publicly accessible knowledge bases is a key challenge. The only justification for using a particular ICT intervention is that the benefits justify the costs (PAHO, 1999). Those benefits must be identified, not only in monetary terms but also consider improvements in access, quality of care, better return of resource utilisation, better clinical end results, user satisfaction, and improvement of the overall community health status. Given the limited and finite resources faced by health decision makers, the right choices can be reached only by appraising the alternative options to see which carries most added value, as well as being affordable and within budgets. Unfounded vendor-driven expectations of how the Internet will revolutionise health care have too often overshot their target (Price Waterhouse Coopers, 2000). Overestimation of results This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 36 and consequent unfounded expectations is a common pitfall. A common error has been to regard technology as the solution for logistical, administrative, and knowledge management problems of healthcare. The lesson to be learned for the use of ICTs in health is that technology can be justified economically only if organisations deploy it in a real practice environment and closely track how managers and direct care professionals are using it. This requires the stepwise development and implementation of processes and metrics to monitor productivity and impact (Hagland, 2001; Yaffe, 2001). When investing in ICTs, a number of key criteria for evaluating and approving the project must be considered. Investments in ICTs are no different to other significant investments in terms of the procedures they must follow and the need for rigorously constructed business plans (PAHO, 1998). The types of questions that could help include: · Is the investment consistent with the ICT strategy of the country or institution? · Will the investment support the broader goals and objectives of the implementing body? · Is there a realistic business plan? · Have the benefits been assessed and a commitment to achieving those benefits obtained from those most affected by the change? · Has consideration been given to achieving those benefits through another route? (What happens if there is no investment? Can current practices be modified to achieve the same change? Are ICTs necessary to achieve the change?) · Has a risk assessment been done? · Is there clear understanding of the procurement process? · Has a project manager been identified and is there a robust and structured system for implementing the plan? · Is there a commitment from senior managers to implement and provide leadership? · Are there sufficient technical skills? · Have sufficient resources been devoted to training and capacity development? · Is there a clear monitoring and evaluation process in place? Part of the cost benefit analysis includes the question of sustainability. Interventions need to be designed that will not only have an impact in the immediate future but for many years to come. Sustainability issues can include ongoing upgrades, training, and maintenance of the system. ICT projects, particularly those dealing with information systems, are notorious for running over time and over budget, yet often still failing to deliver all the specified functions satisfactorily. This can be largely avoided by effective project management, including planning, quality assurance, and resource management components. Obtaining an effective system is not simply a process of competitive tendering, local development, or acceptance of an externally funded donated system. The procurement process should be planned and structured, in order to match the solution to the need and circumstances. This in turn needs a systematic approach to defining the requirements and the available resources, including running costs and staff availability. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 37 5. Emerging trends and potential impact of ICTs Predicting the future in the ICT sector is a hazardous occupation. As the Inter-American Development Bank (IDB, 2005) notes, the rate of technological innovation accelerates technological obsolescence. Technologies are changing rapidly and so too are opportunities. Nonetheless, some broad predictions are possible. 5.1 Emerging trends Five areas of technology likely to offer strong potential for new developments are: · Wireless access to the Internet · Wider use of telephones, particularly mobile telephony · Greater exploitation of the power and reach of radio, and the ability of radio content to be locally determined · The use of digital video techniques to enable local language communication tools · Greater focus on combinations of technologies. 5.1.1 Wireless access Wireless Internet has the potential to provide low-cost broadband Internet connectivity to underserved and remote areas. Leapfrogging the delivery of a wired infrastructure by moving to wireless or radio technologies is also attractive to developing countries (Wireless Internet Institute, 2003). Wireless technologies may be deployed rapidly to help foster economic development and workforce productivity and to enable delivery of applications in the areas of e-health, e-education, and e-government. Example12 demonstrates how such an approach is beginning to transform life in rural Indian villages. Example 12: Wireless internet access in rural India In Tamil Nadu state in India, the Sustainable Access in Rural India (SARI) programme has helped connect wirelessly some 8000 people in more than 50 villages to the Internet. This involved public, private and academic collaboration and helps to set up local service providers operating local telecentre kiosks for little more than an initial $1000 investment. Among the applications of the kiosks is a partnership with the Aravind Eye Hospital to provide online eye consultations. Kiosk operators are trained to take pictures of eyes and email them to hospital doctors. Based on these images, doctors can make a preliminary diagnosis and recommend various courses of action: make an appointment, try a home remedy, visit a local eye clinic, undergo an operation. Some 80 patients used the service during a six month period. The lessons from the SARI project have been shared and the experience replicated in 7 other Indian states, through another 16 projects. The aim is to cover some 500,000 villages over a period of five years, thus providing access to some 85 per cent of India's rural population. Source: Wireless Internet Institute, 2003 5.1.2 Telephony A recent study (Micevska, 2005) has identified a strong connection between the use of the telephone and an increased demand for health services in Bangladesh, Peru and Laos. The analysis at the household level shows that a basic telephone service offers opportunities in delivering timely information on health services to households with relatively greater demand for this type of information. Health workers will be able to track and monitor patients' symptoms using mobile phones with text capabilities in conjunction with a central database. For example, visiting nurses in the field might ask people living with HIV or people with TB a series of yes/no questions about their status, symptoms and as well as reactions to particular medications. They can This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 38 also assess the need for more medication in a particular area. This yes/no information can be entered into a mobile phone and sent to a central database. By creating an up to date database of health information, health workers can track infectious diseases in remote areas, coordinate medical supplies and make better decisions based on more accurate information. In Egypt, mobile phones have been used to promote maternal and child health. Home delivery was discussed by mobile phone users in rural areas and the phones used to mobilise assistance or transport to qualified health workers if deliveries proved problematic (Anon, 2005). Example 13 describes how mobile phones are being used in South Africa by 80 counsellors to support people living with HIV to follow the treatment plan for their anti-retroviral drugs and how text messages are helping TB patients remember to take their drugs. Example 13: Mobile phones keep track of HIV and TB treatments South African researchers have developed novel applications for mobile phone technology that improves adherence to HIV and TB treatments. These approaches have obvious benefits for the patients as well as helping to improve the health infrastructure and monitoring systems. The Cell-Life project, backed by local mobile phone giant Vodacom, has developed software and data management systems that let clinic workers use their mobile phones to monitor patients' HIV treatment and spot health problems before they become life-threatening. The phones are loaded with R55 (US$8.50) in airtime each month and equipped with a special menu that enables HIV counsellors to record data on a patient's symptoms and whether they are sticking to drug regimes, as well as other factors that might affect their health -- such as a lack of money to pay for transport to the clinic, or a shortage of food. The information collected is instantly relayed over Vodacom's network to a central database, which clinic staff can access over a secure Internet connection. Cell-Life has just completed successful pilot projects in townships in Cape Town and Durban, in which about 80 counsellors were trained to use the mobile phones and kept track of nearly 800 patients. There are plans to expand the project's reach into other provinces, and to develop 'reverse billing' software that will enable the clinic to be charged instead of the counsellors using the mobile phones. They could then contact clinic staff in an emergency even if they had no airtime left -- a measure that could save lives in communities with few fixed-line phones. There is also a plan to bring South Africa's other mobile phone networks, MTN and Cell-C, into the project. On Cue, a small company in Cape Town formed by Dr David Green, a TB specialist, has developed a system to send text messages to patients via mobile phones, reminding them to take their medication at pre-determined times. It aims to provide an affordable solution to improve patient adherence to treatment and to reduce associated costs for both patients and clinics. The names and phone numbers of patients are entered on a database and every half an hour the On Cue server reads the database and sends personalised messages to selected patients reminding them about their medication. The messages can be sent in one of three languages and in a range of styles to ensure they do not become boring. Of the 138 patients involved in the pilot, there was only one treatment failure. The idea is now being extended to other areas. Sources: Kahn, 2004 and www.bridges.org 5.1.3 Radio The most enduring and established of ICTs, radio continues to maintain a central position in developing country health communication. A DFID issues paper (Skuse, 2004) points to the contribution of community, national and international radio to health programmes in the developing world and describes it as as a strategic tool for human development and poverty reduction. There is a wealth of experience of radio health initiatives described by Gumucio (2002), or cited on the Communication Initiative website (www.comminit.com/radio). `Soul City' is a high profile health communication programme in South Africa that uses radio, TV and other media. It has built strong monitoring and evaluation processes into its work and is able to demonstrate strong impact in terms of knowledge, awareness, understanding and This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 39 change of practice in selected issues it has covered. Commentators rate radio highly as a cost effective, high penetration medium which offers affordable communication support services to remote, poorly-equipped and minimally-staffed health facilities and communities. (Davies, et al, 2005).The established nature of the radio medium and its key role in decades of health communication mean that it enjoys an analytical credibility that other more new ICTs still lack. The liberalisation of broadcasting in many developing countries plays a role in enhancing the position of radio as a powerful health communication route, although conversely commentators such as Skuse (2005) point to this increased density of media, radio and TV, as a potential danger. `This has critical implications for how health messages are communicated, since there is very real potential for important health messages to be lost in a sea of media. Organisations such as the BBC Service Trust and Massive Effort respond to this by increasing the volume and density of messages in response. So increasingly, increased media complexity may force us to either 'upscale' on mass health promotion campaigns or 'go local' and use community mobilisation increasingly to get messages across.' 5.1.4 Digital video Health workers in villages can now carry VCD and DVD players which instead of flipcharts can communicate a basic message that can then be followed through with discussion. In the past video has been expensive to make and difficult to show in rural areas. Production of a video can now be done on a basic computer, and the cost of making a local language video produced by local health workers is less than a few hundred dollars. And showing the video can be done with portable digital players - and its only going to get easier. Gamos has explored this in Mexico, Moldova, South Africa, Cambodia and Ghana. Its impact studies show a remarkable change to knowledge and behaviour based on the videos. This heralds a large potential tool - in Ghana a number of agencies, including the Health Foundation of Ghana, have now had their staff trained and are beginning to develop local language videos that can be shared with each other (Gamos, 2005). 5.1.5 Convergence and combination of technologies Convergence and combination of technologies can help many developing countries to improve access to medical records for patients and to improve access to health information for patients and health workers. It has long been recognised, as a DFID report in 2001 noted, that `a combination of new ICTs and traditional media can provide the widest coverage and ensure that those excluded from education by virtue of poverty, gender, geographical remoteness or conflict are not excluded' (Skuse, 2001). Deciding which technologies to use `should be determined mainly by the specific local context and demand' (Weigel and Waldburger, 2004). In Kenya, AfriAfya has been working for more than five years to explore innovative ways of combining ICTs in different field settings, as Example 14 demonstrates. Its experience underlines the importance of undertaking information needs assessments ­ finding out what information people want ­ rather than simply supplying them with what is available. It also was quickly evident that despite the large amount of information available on the Internet, very little is directly suitable for dissemination to poor communities as it is. It needs to be repackaged to ensure local suitability and relevance. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 40 Example 14: AfriAfya ­ working with a combination of ICTs The idea for AfriAfya - African Network for Health Knowledge Management and Communication - is based on the realization that modern ICTs have done almost nothing for rural communities. It was established in April 2000 by Kenyan-based health and development agencies to explore harnessing modern ICTs for community health among marginalized communities. Working with communities in different parts of the country, a small hub has coordinated a two-way system of information exchange. Through this, AfriAfya has implemented programme activities that use a combination of satellite technology, radio, video, print, electronic communication through email, text messages on mobile phones, CD ROMs, telephone, post, folksongs and traditional media to improve access to health information, with HIV/AIDS as the pathfinder topic. AfriAfya has demonstrated the use of appropriate information and communication technologies (ICTs) to generate, manage and disseminate information. Some of the activities include · Training change agents in information management skills and application of ICTs to access, produce and share health and other development information · Establishing community-based resource centres · Working with communities to respond to information gaps · Collecting, repackaging and disseminating health and other development information. Content is generated from the experience and questions provided by the communities involved. This is augmented by official publications from the MoH, the National AIDS and STDs Control Programme, AfriAfya Partner Agencies, other HIV/AIDS organisations in the country, and from the Internet. The information is repackaged by the hub and sent to the field centres for use by frontline health workers and change agents, helping them to deal with health problems and questions raised by lay community members. Questions from the field centres include: · simple factual issues (Can one get AIDS from being bitten by the mosquito? How effective is the condom in preventing HIV transmission?) · social issues (How can I deal with the unfaithful drunken husband who will not agree to condom use?) · cultural issues that promote the spread of HIV/AIDS (How can we deal with `matanga' - funeral rites that involve a lot of sexual activity thus contributing to spread) · community experiences gained over time (Is it true that engine oil or specified toothpastes can help to relieve HIV-related skin lesions?). Source: Adapted from a case study by Caroline Nyamai-Kisai in Ballantyne, 2002 The convergence of new and old technologies is well documented in a report from FAO (Girard, 2003) that presents examples of converging radio and new ICTs for development. The report argues that radio will have even greater significance and value in years to come. Particularly relevant is the chapter on `Take Five: A handful of essentials for ICTs in development' by Alfonso Gumucio Dagron where he describes a set of `non-negotiable conditions for ICTs in development': · Community ownership · Local content · Appropriate technology · Language and cultural pertinence · Convergence and networking. The advent of wireless Internet access potentially allows the use handheld communication devices, web-enabled telephones, interactive television, web and email terminals (Eng, 2001; Primo Braga, 2003; WideRay and Satellife, 2003). The novelty and improved efficiency of new technologies may have the biggest effect on the acceptance of second-generation technologies in youth programs (IPPF/WHR 2001). There is a need to identify or develop methodologies for passing content from one medium to another, for example, from the Internet to community radio. Several organizations are modifying computer technology to make it more appropriate for rural areas; for example, the Simputer is being developed in India for rural low-literate populations (Harvey 2002). By using online broadcasting, radio stations can increase their range, from local to global, sharing health content and opinion, and enhancing the value of effective health programming This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 41 by enabling it to be heard more widely. Online health communication resources, such as the Aids Media Center portal for sharing HIV and AIDS communication news and resources for developing country media (www.aidsmedia.org ) help to extend the reach. The mix of radio broadcasting and satellite, for example Worldspace satellite radio, is also another example of how old and new technologies are combining to enhance health communications. Nearly every type of new ICT presents an opportunity for synergy with radio broadcasting for health. 5.1.6 Continual technological development Advances in digital and compression technologies mean that vast amounts of information can now be stored on smaller and smaller chips so that up-to-date digital medical libraries and databases can be developed and searched online over the Internet or stored on a laptop computer or on smaller hand held devices such as a PDA (or an IPOD). In the near future, health workers in developing countries will be able to access these databases from remote sites. Thus a rural physician could search a vast online Internet database of medical articles for information describing a rare disease and its possible presentations; or nurses in remote areas could individually access continuing education classes via a desktop computer along with a web camera; or government officials could conduct HIV and AIDS training and education on a regional level using videoconferencing centres. Additionally, the introduction of electronic medical records on a more comprehensive basis could provide an effective mechanism for health workers to keep good records on which public health information systems can draw, track and monitor. The development of good records and accurate data is becoming a critical global issue with the incidence of AIDS, SARS and other communicable borderless diseases. Clear lessons around the emergence of new technologies include the advantages of integrating ICT activities into other programmes, the benefits and strengths of building on existing systems and structures and the need to stimulate and foster telecommunication sector reform processes. ICT projects appear to be more likely to be successful when they are added as enhancements to pre-existing projects with established goals and guidelines for outcomes. According to Johns Hopkins University (Maxfield 2004), ICTs cannot stand alone in most health programmes and need to be integrated into them so the strengths of the ICTs complement other approaches. This underlines the need to ask how ICTs will contribute to real enhancements and improvements in the health of people rather than simply promoting connectivity as a good thing. Building on existing structures is quicker than starting from scratch ­ working with already established health intervention sites has allowed AfriAfya to jump-start and bypass many of the very time consuming start-up stages. There are strong indications that impact can be made through encouraging public-private partnerships and enhancing mechanism for financing such ventures 5.2 Potential impact on individual behaviour and decision making A crucial question to address when looking at ICTs in health: `What is the potential impact of information and communication on individual behaviour, and on individual health decision This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 42 making'? Examining the question of incentives for individuals to absorb and act upon health information is also a vital area of consideration. When looking at the impact of ICTs on individual behaviour and decision-making it is necessary to first look at the impact of the communication itself, not solely the delivery mechanisms for that communication. The positive impact of the ICTs will only be as good as the quality of the communication conveyed, and if ICTs enable the generation of new styles and types of communication that address peoples needs in new ways then impact might be seen to be beneficial. An example of the potential impact of ICTs on an individual's access to information and increased communication can be seen in various health areas, with HIV and AIDS being particularly illustrative as many websites, e-forums and e-resources have been developed directed at beneficiaries who range from the general public to people living with HIV/AIDS, from health workers to treatment activists. The table below gives a taste of the variety and density of ICT enabled tools that are being produced and accessed. Table 5: Reproductive health activities benefiting from ICTs Activity ICT applications Examples · Free medical journals (www.freemedicaljournals.com) · Literature databases · id21health (www.id21.org/health/) · Libraries · Eldis (www.eldis.org) Research · Online collections of · PRB e-library (www.prb.org/email) PDF documents · Population and Health Info Share(www.phishare.org) available to email · RH gateway (www.rhgateway.org/) · African Journals Online (www.ajol.org) · Afro-Nets (www.afronets.org/index.php) · Electronic discussion · Interagency Gender Working Group (www.igwg.org/) groups moderated listserv (to join, email igwg@prb.org) · WHO's Health Information Forum (HIF-net) email discussion Networking · Conference announcements and list (to join, email health@inasp.info) proceedings · Second Asia Pacific Conference on Reproductive and · Professional websites Sexual Health (www.apcrsh.com/) · The Association of Uganda Women Medical Doctors (www.auwmd.interconnection.org/) · Email discussion lists · Saathii (www.saathii.org) Advocacy · Online newsletters · Microbicides (www.global-campaign.org/resources.htm) · Websites · Angel Coalition (www.angelcoalition.org/) · PowerPoint curricula · Supercourse (www.pitt.edu/) · Blended web and other · Virtual campus of Public Health (www.campusvirtualsp.org/eng/index.html) technologies Health worker · TALC (www.jhpiego.org/) education and · Learning centers · EngenderHealth modules (www.engenderhealth.org/) training · CD-ROMs · Emailed newsletters, · JHPIEGO TrainerNews®(community.jhpiego.jhu.edu/) updates · Adapting to Change training (www.reprohealth.org/) · Video conferencing · ITCAN Information and Communication Technology Capacity Building for Asia Network (www.it-can.org) · Blended combinations of · Soul City (www.soulcity.org.za/) Reaching youth radio, video, websites · HIV/AIDS telephone helpline, Rajasthan, India · Telephone hotline (www.comminit.com/) Improving · Handheld computers for · Community Access to Sustainable Health (Ca:sh) This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 43 health systems rural health workers to (http://kaash.sourceforge.net/) collect data · Push Journal (www.pushjournal.org/) · Emailed updates on "What's new" · The PopReporter (www.infoforhealth.org/popreporter/) sexual and reproductive health · OneWorld.net (www.oneworld.net) · Digital Opportunity Channel (www.digitalopportunity.org) Source: PATH, http://www.rho.org/html/ict_table1.htm This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 44 6. Lessons The types of strategies that are more likely to improve healthcare (and livelihoods, the quality of education and advance community economic growth) are those that look beyond merely providing access to ICTs and embrace more holistic approaches such as fostering equitable access, supporting meaningful use of ICTs and encouraging community and user self- empowerment through appropriating the use of the technology (Michiels and Van Crowder, 2001). A number of review studies and analytical papers have attempted to pull key lessons out from the many ICT projects that have been undertaken over the years, both in the health sector and in other sectors. Danida (2005) looked at 16 ICT and health projects based in Latin America, Africa and Asia. Batchelor et al (2003) explored 17 infoDev projects. A report for CIDA (Feek, 2003) examined 60 projects from around the world. IICD (Ballantyne, 2002) studied some 30 local content examples. Johns Hopkins University (Maxfield, 2004) looked at 22 health communication projects. The FAO (Michiels and Crowder, 2001) explored telecentres. The NGO Practical Action (Talyarkhan, et al 2005) looked at a number of examples dealing with poverty impact. The Swiss Agency for Development and Cooperation (SDC) and the M.S. Swaminathan Research Foundation explored lessons on upscaling pro- poor ICT policies and practices (Gerster and Zimmerman, 2005). From these studies, 12 key lessons are evident that can be used to guide future work in the use of ICTs in any sector. Table 6 highlights the lessons, and identifies the way such lessons could be used. This framework paper has also identified a number of key lessons specific to the use of ICTs in the health sector in developing countries. A summary of these key lessons as they relate to intermediaries and beneficiaries, to improving the functioning of health care systems, to improving health care delivery and to improving health communication is provided below. Critical requirements for implement ICT programmes in the health sector are also identified. This is followed by lessons about why health ICT programmes fail. There are still major knowledge gaps and some of these are identified. This section concludes with lessons about a possible model for scaling up or expanding successful interventions in the use of ICTs in the health sector. Table 6: Lessons and possible actions Lesson Possible action 1. Technology is not an end in itself, but a Integrate and mainstream the use of ICTs tool to enhance existing work, strengthen into existing programmes and systems existing systems, achieve broader health and development goals and meet locally determined needs 2. Successful inclusion of ICTs in ongoing Undertake stakeholder analysis; encourage health programming depends on the active stakeholder involvement and participation involvement of beneficiaries and end users from the beginning in determining information needs, type of content and the most appropriate technology to use 3. Local conditions determine success Prioritise locally available and accessible technical solutions. 4. The simplest possible technology solution Build on and complement information and is likely to the most appropriate, user friendly communication technologies already being and sustainable. used 5. No single technology will be suitable for all Combine old and new ICTs in creative and situations. innovative ways This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 45 6. Capacity development and training Invest in capacity development ­ for components need to be included in all ICT technological skills, communication skills, initiatives and content development skills 7. Developing local and international multi- Encourage the development of partnerships stakeholder partnerships supports at local, national, regional and international communities to become more self-sufficient levels through capacity enhancement, and by building on existing formal and non-formal communication networks 8. The enabling environment is crucial to Ensure the infrastructure required by the providing information and communication technology being used is in place, or in the services, innovation and entrepreneurship process of being put in place and free flow of information 9. Regular monitoring and evaluation of Incorporate plans for monitoring, evaluation impact generates successful use of ICTs and impact assessment to ensure critical evaluation of efforts, adaptation, and opportunities to involve beneficiaries and end users in continuous dialogue about progress 10. Sharing learning and disseminating Introduce learning processes and experience improves practice and frameworks understanding of the different ways people Develop links with others doing similar ICT learn, communicate and use information interventions 11, Addressing the needs of the poor and Consider gender, inclusion and participation most marginalised, particularly women and of the most marginalised in all planning girls is vital 12. A clear and expressed plan for Plan all programmes that include ICTs to sustainability ensures that capital achieve both short term and long term replacement and operating costs are objectives identified up front as well as ICT infrastructure requirements and capacity to maintain the programme and its impact 6.1 Summary of key lessons about the use of ICTs in health Beneficiaries · Target beneficiaries need to be clearly identified and their needs clearly mapped at the start of an ICT intervention. · Beneficiaries need to be involved in the planning, development and use of the intervention. Intermediaries · Intermediaries need capacity to take on the new ICT innovation. · Without this capacity the innovation will not translate into an embedded and sustainable benefit. Improving the functioning of health care systems · Explicitly identify the objectives and expected results of any information system. · Engage all participants (from the developers of the system to the users and beneficiaries) to ensure they see the innovation as adding value to existing systems and that they are able to use it, and can see the benefits. · Information systems must never become static, or they lose their value. ICTs in health care delivery This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 46 · Telemedicine provides benefits of resource coordination, urban/rural linkages and connects remote health staff to centralised health expertise and resources. · Incorporating already existing technology ­ such as phone or email ­ into medical practice and routine consultancies can make a difference. · There is strong potential for e-learning in health as demonstrated by a variety of successful small projects around the world. · Multiple ICT routes can, and are, being used for e-learning in a mixed toolbox approach (for example: including Internet, radio, SMS, PDAs and combining with print). Role and potential of ICTs in improving communication around health · There is growing evidence that ICTs aid health information dissemination, particularly via online routes. · There is growing evidence that ICTs increase the effectiveness of some communication systems. · Through the provision of increased communication access, more people are `linked in' to communication opportunities. · Mass media ICTs, such as radio, remain key aspects in communicating about health. · There are demonstrable benefits in combining technologies, particular older with newer ICTs. · Health information via the media should not be rushed, and is still constrained by traditional constraints of communication strategies. 6.2 Critical requirements for successful implementation of health ICTs These lessons lead to the identification of a number of critical requirements for the successful implementation of ICT projects and programmes in the health sector of developing countries. These include identifying: · purpose, strategies and scope of services to be provided · audiences, customers and users (targeted populations) · value of health and healthcare to the individual and community · current ways to assess individual and collective health problems (community health) · needs of the individual, community, and nation · institutional user needs and commitments · competencies of the organisation implementing or hosting the ICT system. Whether at an organisational or institutional level (a hospital, a university medical school, a health centre) or at a national level (within the health ministry or across the health system), determining the core objectives, clients, competitors, and competencies in terms both of health service provision and information capabilities are important requirements for introducing ICTs successfully. This involves examining · Governance ­ the collection of rules and policies that guide how an institution or the health system operates, including its social, economic, political, and legal ownership choices. (This also includes looking at structures, processes and skills and competencies.) · Technology governance - the set of policies that control ownership decisions, set rules and standards for, and regulate the use of ICTs · ICTs strategy ­ determining which technologies will best meet the purpose and support the policy objectives This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 47 · Capacity ­ including project management, information and knowledge management technology, communication skills to repackage and share information · Standards - rules and standards governing the operation of the ICTs must be set so that the technology meets everyone's expectations and delivers what was promised · Costs and budgeting ­ budgets need to cover maintenance of systems, salaries for information staff and the capital expenditure and operation budgets, as well as training costs. 6.3 Lessons about why health ICT projects fail There is evidence to show that many ICT projects do not succeed and have little or no sustainability. Richard Heeks (2002) states that one-third of all ICT projects will be complete failures, while over half will be partial failures. Many reasons can be cited for why ICT and health interventions do not succeed. WHO (2004) has identified a number of factors in relation to national programmes: · lack of proper needs assessment · lack of vision, strategy and national plans · lack of information and awareness about ICT applications · computer illiteracy · insufficient resources to meet costs · limited experience in medical informatics · weak information and telecommunications infrastructures · absence of legislative, ethical and constitutional frameworks. A risk assessment technique has been developed by Manchester University in the UK to help determine whether an ICT and health project is likely to succeed or fail (see: www.egov4dev.org/ehealthriskdrgap.html). The benefit of such a tool is that it helps to identify the key risk factors in time to be able to respond and mitigate against the risk. 6.4 Lessons about knowledge gaps Beyond that, there are still questions that need resolution and areas where further investigation can help to extend our understanding and evidence base. The biggest question is how to move from proof of concept to large-scale implementation? This needs more research, more understanding of what makes for effective large scale approaches. Initial indications are that combining a number of successful smaller scale approaches that suit diverse local conditions is likely to be more effective than struggling to find a single approach that can work in every situation. This is explored in more detail in Section 6.5. Four key questions that need further investigation to help to extend understanding and the evidence base about the use of ICTs in the health sector are: · How to evaluate the impact of the use of ICTs on health? · What can be done to strengthen the role of and build the capacity of local information intermediaries? · How can local content that is relevant, appropriate and practical be developed? · How to enable the voices of those most affected by ill health to be heard? Monitoring and evaluation processes provide valuable learning opportunities to improve programme design, both for future activities, but also to adjust existing programmes. Few tools exist to assist programme managers and agencies to evaluate weaknesses in their ICT and health programme design and make mid-stream corrections to their programme frameworks. Yet experience has demonstrated the importance of local improvisation and This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 48 adaptation for programme success. Focusing on the development of and use of participatory and simple evaluation tools, methods and models can make a huge contribution to the learning around the use of ICTs in health. This is an area where further research would be useful to help develop effective tools and processes. Recently, WHO has established a network of centres ­ the e-Health Global Observatory ­ which will systematically analyse and report on the use of e-health in different countries. This should contribute to the evidence base that can further inform policy and practice (WHO, 2006). Intermediaries who can transform global information into useful, practical and relevant knowledge for local people and who can take local knowledge and repackage it for sharing more widely are critical in ensuring the effective use of ICTs in the health sector. Programme designs should consider the role of the intermediary at the same time as, if not before, the role of the technology. The time and money spent on developing training and capacity strengthening programmes and curricula for various types of intermediaries is at least as, if not more, important than that spent on technological adaptations and modifications. Because of the significance of intermediaries, policy and programme design should increasingly look to identify the position and roles of the intermediaries first and then complement them with appropriate technological solutions. These facilitators of information should be enabled to make adjustments and modifications to designs and implementation strategies and as well as the reassessment of project goals and outcomes. Increased support is needed for people experiencing and working on health issues to use ICTs to: · create health content from their experience relevant to their contexts and issues for their neighbourhoods, communities and countries · tell their stories · communicate the lessons from their experiences · support each other with their health actions (Feek, 2003). Related to this is the need to train and foster more local content generators. Human capacity building is required in both hard skills (like networking) and in human communication skills like marketing, journalism, research and leadership. These combinations of skills will result in individuals who are well equipped to both transform the information on the Internet and to contribute to that larger pool of knowledge. The people who use health care services are part of the solution. Too little priority has been placed on the use of ICTs to increase the voice of people directly affected or threatened by health issues in policy development, programme review, critical thinking and programme management roles. ICTs lend themselves to pushing information to intended beneficiaries (Feek, 2003). Much less work has been done to enable those most affected by ill health to share their knowledge, understanding, experience and ideas for change. Johns Hopkins University (Maxfield, 2004) predicts that ICTs will make additional demands on health communicators. The interactivity of the technology will demand practitioners with skills and competencies more in line with counselling, conflict resolution and mediation and other dialogic skills rather than advertising or marketing. This is an area where much more work needs to be done to develop effective tools and processes, and more investment needs to be made in building capacity. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 49 This means a move from the use of ICTs to enable uni-directional message delivery and towards increasing dialogue and interaction among those who are directly affected by poverty and ill health, health workers, and policy makers. 6.5 Lessons about staged development Developing successful health programmes that make effective use of ICTs means paying attention to the lessons learned from past experience. A key lesson is that there is no single technology, no single approach, no single intervention that will work everywhere. The policy decisions on what to scale up in a particular country depend on the local circumstances. A careful review of the use of ICTs in a number of African countries carried out by the SCAN- ICT project found in Mozambique, for example, that small scale approaches were likely to be more effective than mega-projects and would have `a bigger impact on community development' (Eduardo Mondlane University 2002). Also, the local/national telecommunication infrastructure plays a key role in what choices can be made. Johns Hopkins University (Maxfield, 2004) says decisions about the use of ICTs in health programmes should be made at the country level. The World Bank (2003) suggests that the challenges and the solutions to them will vary not just from country to country, but from city to city and community to community. This underpins the critical approach of ensuring that a situational and needs analysis is part of the planning for the use of ICTs. The local situation is key to determining which approach is likely to be most effective. The use of needs assessments to clarify local situations is a pre-requisite for an effective programme. Also, as the experience of AfriAfya in Kenya (see Example 14) found, networking, collaboration and ongoing partnership between different health organisations and institutions can be successfully developed. 6.5.1 A context specific approach The starting point for most ICT interventions has tended to be at the high end of the technology, when the reality is that people need to begin with what is available in their particular setting. Considering the evidence and the lessons about ICTs in health in the developing country context a new framework to analyse the impact of ICTs on health could be very timely in developing new strategies. There is considerable evidence of positive impact of ICTs in health in the Western context. However this is predicated on capacity, resources, institutional support and many other `enabling' factors. It is therefore not difficult to assess ICT potential in this context. When transferred to developing country contexts these enabling factors are often compromised and/or missing, and this reality needs to be taken on board by all policy makers considering ICT interventions and scale-ups. Small scale is the only possibility in many places because the basic health infrastructure is not in place; the political will is lacking; the money is not available and may never be in our lifetime. A way forward could be to look at a step change framework rather than trying to introduce a predefined system. It is therefore proposed that policy makers consider the use of ICTs in health as a process that needs to firmly established, with locally appropriate and sustainable foundations, before the rest of the structure or system is developed. In a step change framework a starting point would be examining and analysing what exists at a local level. Each level would be determined by assessing the context. It would move gradually or swiftly depending on enabling factors to more advanced levels of application that go beyond the local and small scale and move into larger scale-up. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 50 It is proposed that the learning from small scale successes should be applied and the successes replicated in other locations on the same level. The shift from a basic level to an advanced level in a large-scale scale-up might not be advisable as the enabling factors may not be in evidence. Only when they are clearly established and when they are comparable should large-scale scale-up be contemplated. 6.5.2 A step change framework A step change framework for `ICTs in health' development in developing countries takes account of the level of the intervention, the enabling factors that are necessary, the evidence and learning that is achieved and the learning that this feeds into scale-up potential. With the knowledge that the application of ICT strategies in the developing world context is contingent on a minimum of enabling conditions being in place, it is then a question of decision-making about strategic directions; options include developing more and more small scale interventions in locations where enabling factors are in evidence, developing shared learning about effective interventions and then applying this in a range of new situations. The scale of ICT interventions and initiatives needs to be understood, because there is no one size fits all, there are graduations of projects, engagement and development. Once these aspects have been explored it is then possible to outline the scale-up potential. The following is an example of a step change table ICT project levels Enabling Evidence/learning Scale up potential factors Basic Level local knowledge adaptation of new users of basic of how to use technologies to fit local technology can be appropriate context; new skills trainers for local technology developed users and can have skills enhanced Medium Level reasonable benefits of new access to intermediaries literacy and information clearly available to introduce numeracy levels; evident; increased and support low cost access dialogue about health technology and to to appropriate issues leads to increased adapt and modify technology; demand for facilities, content higher level services and technology support accessible High Level regular systems driven by needs likelihood of large connectivity; low assessment and number of acceptors cost access to appropriateness of and users technology; approach, rather than strong capacity technology . This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 51 7. Conclusions The scope of this study has been finite and modest, and it is hoped that the knowledge gaps and other identified areas of focus that have been highlighted in this paper will be further researched in order to build a strong body of evidence and analysis about ICT and health. This document can only go so far in signposting areas for further inquiry. It is also clear that even at this early stage in the evolution of ICTs there is a developing body of evidence, primarily in the western context, which points to a range of benefits and efficiency savings for individuals and institutions in health. This body of evidence is not easily transposed onto developing country context, and the range of contextual issues around the world mean that ready-fit `one size fits all' conclusions are difficult and dangerous to make. However the range of benefits that are being highlighted in various small scale case studies are building a base of tentative evidence in the developing world for the application of ICT strategies. These provide a compelling indication that there are benefits in ICT implementation in health, but that they need to be understood in context and scaled-up carefully. Seven broad conclusions can be drawn about the use of ICTs in the health sector. These seven should be applicable at all levels, and although they are expressed simply here, the complexity of putting them into practice is one of the biggest challenges we face in ensuring that the health system benefits, that health workers benefits, and that the people who make use of the health system ­ the patients and citizens ­ benefit and their health improves. 1. Keep the technology simple, relevant and local. 2. Build on what is there (and being used). 3. Involve users in the design (by demonstrating benefit). 4. Strengthen capacity to use, work with and develop effective ICTs. 5. Introduce greater monitoring and evaluation, particularly participatory approaches. 6. Include communication strategies in the design of ICT projects. 7. Continue to research and share learning about what works, and what fails. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 52 8. References This framework paper draws extensively on a thorough literature review and on-line fully searchable database that was developed as part of the research. In total, more than 2000 materials were identified and assessed. The full database contains more than 400 key materials and is accessible at www.asksource.info/res_library/ict.htm together with an annotated bibliography. The references below are the main ones used in the development of this paper. Ahmed, M. 2004. 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Available at: http://www.hospitalmanagement.net/informer/management/diagnostics1/index.html Weigel, G and Waldburger, D. 2004. ICT4D - Connecting people for a better world: Lessons, innovations and perspectives of information and communication technologies in development. Berne/Kuala Lumpur: SDC/GKP This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 57 WideRay Corporation and SATELLIFE, 2003. Uganda battles disease through wireless health care infrastructure Available at: www.wideray.com/. Wild, K. 2003. Measuring and enhancing the impact of ICTs on the MDGs 4th Session of the United Nations ICT Task Force, Geneva, 21-22 February 2003. www.ictwhoiswho.net/uploads/forums/13/192/KateWild-ictmdgfinalfeb9.doc Wilson, E and Wong, K 2000. African Information Revolution: a balance sheet (draft); http://www.bsos.umd.edu/cidcm/events/AIR.htm Wireless Internet Institute (ed.) 2003. The Wireless Internet Opportunity for Developing Countries. 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Cambridge, MA: Giga Information Group Inc This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 58 Appendix 1: Body of Evidence Major Reviews of the Evidence Base for the Use of Information and Communications Technologies for Delivery of Healthcare services Review Topics/ Comments reference ICTs in Health Review of literature from 1982 ­ 2002, showing the number of lab Evaluation Trends studies and technology evaluations declined with more emphasis on Amenworth and De the influence of IT on quality of care process or patient care, Keiser (2005) interpreted as maturation of evaluation research in the field Remote Systematic review identifying nine articles with only one RCT of Interpretation using telephone or videoconference for language and Azarmina and Wallace communication interpretation purposes; results suggest remote (2005) interpretation is acceptable and accurate, but with higher associated costs Electronic This systematic review looked at 80 RCTs of computerised Communication with communication, telephone follow up, counselling, telephone patients reminders, interactive telephone systems, after hours telephone Balas et al (1997) access and telephone screening. Electronic communications with patients were seen to both improve access and support the coordination of clinical activities. Patient satisfaction Systematic review of 93 studies, demonstrating levels of 80%-100% Williams et al (2001) satisfaction with telehealth care but pointing out major methodological problems in the studies to date (e.g. 2/3 failing to compare with face-to-face standard, half of studies using only 1-2 satisfaction measures) Socioeconomic Systematic review of 4646 citations, analysing 306 sources, finding Impact overall increased access to health services, cost effectiveness, Jennett et al (2003) enhanced educational opportunities, improved health outcomes, quality of care and social support by the use of telehealth applications Systems and Systematic review of the evaluation of telemedicine services, services evaluation concluding that it offers a safe alternative to conventional care but Taylor (2005) that evidence is lacking that it is cost effective and practical if systems and service delivery are lacking. Clinical Outcomes Systematic review of diagnosis, clinical management and clinical Heinzelmann et al outcomes breaking the results into subspecialty uses. Only 1/3 of (2005) studies investigating clinical management or outcomes were based on RCTs with 1/3 of RCTs having less than 30 patients. Comparison of 44 studies (67%) had potential to influence policy; 37 studies conventional and showed defined advantages over conventional care delivery telemedicine service services, 13 showed both advantages and disadvantages of delivery studies telecare, 11 studies unclear about advantages, 5 studies showed Hailey et al (2002) alternative approach had advantages over telemedicine; scarcity of quality RCTs emphasised; includes assessment of and updates the two previous systematic reviews by the International Network of Agencies for Health Technology Assessment (INAHTA) Efficacy of Office/ hospital based, store and forward, and home based services Diagnostic and reviewed 59 articles met inclusion criteria. Use for history and Management physical examination showed good sensitivity and specificity; good Decisions efficacy shown for cardiology and ophthalmology; limited quality of Hersh et al (2002) evidence for generalised use in management decisions Telecardiology The review identified the lack of long term studies with only 21 Bonacina et al (2005) studies reporting project duration of longer than 1 year. Most studies This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 59 were pilot projects with only short term outcomes Increasing access to Although evidence was insufficient to made clear recommendations, primary care in this review suggests that walk-in centres and NHS Direct have underserved provided additional access to primary care for white middle class populations patients rather than to underserved populations, and that these Chapman et al (2004) innovations may actually have increased access inequalities Remote vs face-to- Systematic review showing little evidence of clinical benefits face clinical care although none of the studies showed a detrimental effect of the Currell et al (2000) telemedicine intervention. Suggests that policy makers should be cautious about recommending increased use and investment in unevaluated technologies Dermatology A systematic review of patient satisfaction with telemedicine Demiris et al (2004) applications in dermatology. Fourteen studies identified five regarding store and forward applications with the rest video based interventions. This systematic review demonstrates how methodological weaknesses in the research limit the ability to generalise results. One conclusion was that different telemedicine applications need different satisfaction instruments. Tele-surgery Systematic review giving overview of telemedicine in surgery ­ Eadie et al (2003) including outcomes of studies. Telementoring and teleconferencing have been widely used in surgical training. Telesurgery systems are available and trials have been undertaken in coronary artery bypass, prostatectomy, gastroplasty and cholecystectomy. Outcomes were successful but with prolonged operating times. Improvements are needed in tactile feedback, instrumentation, telecommunication speed and availability. Associated issues of legislation, cost and benefit require clarification Patient-clinician e- A systematic review looking at email communication, between mail communication patient and clinician. The review seeks to provide a set of guiding Eisenbach (2000) ethical principles applicable to these communications. It distinguishes between different media and their appropriateness: email is fine for giving health information while diagnosis and treatment require more advanced telemedical technology. Important lessons for patients and consumers too with the suggestion that it is unethical to diagnose and treat over the internet or in a single email. Remote diabetes A systematic review of clinical studies using electronic transfer of monitoring blood glucose results in people with diabetes. RCT results were Farmer et al (2005) pooled and meta-analysis performed. Although electronic transfer of glucose results appears feasible in a clinical setting, studies were small scale and only 3 extended to over 1 year. Studies did not provide evidence that intervention was effective in reducing HbA(1C) or reducing costs or other aspects of diabetes management. Mass media A Cochrane systematic review looking at the role of mass media interventions: effect (radio, television, newspapers, magazines, leaflets, posters and on health services pamphlets) in influencing the use of health care interventions. This utilisation is an important systematic review on a broad range of media Grilli et al (2002) interventions showing that despite poor quality of some research there is evidence that channels of communication have an important role in influencing use of effective services and discouraging use of unproven effectiveness. Mass media A systematic review to assess the effect of mass media interventions in HIV interventions and the most effective form of mass media and AIDS testing intervention at a general population level or in specific target Vidanapathirana et al populations, in relation to changes in HIV testing, compared with a (2005) control group or with pre-intervention levels. This review demonstrates that mass media campaigns designed to raise awareness of HIV and AIDS have shown immediate and significant effects in the promotion of voluntary counselling and testing for HIV, This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 60 but no significant long-term effect, likely due to the short duration of the campaigns. Remote care of A systematic review of assessment of telecardiology from 1992- cardiac patients 2003 identifying 44 studies meeting selection criteria. Highest Haley et al (2004) quality studies were found on home care applications such as management of heart failure while paediatric and non-emergency adult hospital applications were of poorer quality. No convincing data on influence on health outcomes or cost effectiveness. Health outcomes in The objective of this systematic review was to evaluate the efficacy both home-based of telemedicine interventions. A total of 25 articles met inclusion and office/hospital- criteria and were assessed. The strongest evidence for the efficacy based delivery of of telemedicine in clinical outcomes comes from home-based care telemedicine in the areas of chronic disease management, Hersh et al (2001) hypertension, and AIDS. The value of home glucose monitoring in diabetes mellitus is conflicting. There is also reasonable evidence that telemedicine is comparable to face-to-face care in emergency medicine and is beneficial in surgical and neonatal intensive care units as well as patient transfer in neurosurgery. Economic evaluation The issue of whether telepsychiatry is worth the cost or whether it of remote care in pays for itself is controversial. This study investigated this question Mental Health by reviewing telepsychiatry literature that focused on cost. The Hyler et al (2003) methods of examining cost used in the 12 studies were cost- feasibility, cost surveys, direct comparison of costs of telepsychiatry and in-person psychiatry, and cost analysis. It was concluded that in seven of the studies reported, telepsychiatry was worth the cost. One study reported that telepsychiatry was not financially viable. Three studies of cost-effectiveness reported the break-even number of consultations, the number that make telepsychiatry comparable in cost to in-person psychiatry. Clinical Outcomes in Systematic review and meta-analysis of studies published between remote areas in 1956 and 2002 included 14 studies comparing telepsychiatry with Mental Health in-person psychiatry and high versus low bandwidth telepsychiatry. Hyler et al (2005) The study suggested no difference between telepsychiatry and in person psychiatry in terms of accuracy or satisfaction although anecdotal evidence suggested higher bandwidth was slightly superior for assessments requiring detailed observation of subjects. Authors expected telepsychiatry to replace in person in certain research and clinical situations. Use of Simulation in Systematic review on the use of simulations in medical education Medical Training selected 109 studies meeting criteria. Medical simulations facilitate Issenberg et al (2005) learning under the right conditions. These include providing feedback, repetitive practice, curriculum integration, range of difficulty level, multiple learning strategies, capture clinical variation, controlled environment, individualised learning, defined outcomes and simulator validity. Remote nursing care A systematic review of research published 1966-2001 on telehealth of the elderly interventions in clinical nursing of elders. 18 reports described 8 Jones and Brennan projects showing limited quality evidence based studies. (2002) Use of personal The review shows while adoption and usage of PDAs as an ICT digital assistants intervention is accepted, there are still very few studies that provide (PDAs) in clinical evidence about their impact on patient outcomes. care Kuziemsky et al (2005) Patient satisfaction A systematic review of studies published between 1966 and 1998 with remote found 32 studies, all reporting good levels of patient satisfaction with consultations clinical consultations between health care providers and patients Maier and Whitten involving real time interactive video. Methodological problems (2000) noted. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 61 Appendix 2: Terms of Reference The main objective of this assignment is to perform a knowledge mapping exercise and an expert analysis to produce a paper that presents the current knowledge on the role and use of ICT in the health sector and outlines knowledge gaps. The paper will draw recommendations on priority issues and future trends for policy makers in developing countries and donors working in the health sector. It is anticipated that much material will be in English, but also that analysis of materials appearing in Spanish and French will be included to contribute to the desk research and the online dialogue. The following outputs will be delivered: 1- Knowledge map The knowledge map will feature an annotated bibliography and the gathered information will be organized by the taxonomy described below, and in consultation with infoDev and experts in the field. Materials will be categorized according to this taxonomy as well as additional fields such as language, location, and type of material. The research will identify clear information in each of the intersecting areas across all matrices, covering the following areas: · ICT taxonomy: a) ICTs and health communication, b) e-learning, c) monitoring and evaluation, d). health information, e) evidence base of ICTs in health and development, f) telemedicine, g) health information systems, h) ICTs, organizational behavior and change management, i) connectivity and the digital divide, j) use of satellite based media in health and development, k) use of community based radio and media, l) ICTs and health policy, m) ICTs and emerging technologies in health and development, n) ICTs in disease surveillance and preventative medicine, o) innovative uses of ICTs in public health in developing countries, p) public health and preventive health campaigns using ICTs. · WHO public health functions (adapted): a) prevention, surveillance and disease control ­ health promotion b) occupational and environmental health, c) public health ­ legislation, policy and management, d) public health services and health care for vulnerable populations. · MDGs: a) eradicate extreme poverty, b) reduce child mortality, c) improve maternal health, d) combat HIV/AIDS, malaria and other diseases, e) ensure environmental sustainability, f) develop a global partnership for development. A third area of consideration will relate to regional and country-specific issues, including connectivity and community culture. This geographical focus will use the taxonomy defined by the MDG campaign: East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; and Sub-Sahara Africa. The valuable data gathered in the process of research and stakeholder consultation will be professionally indexed and archived, and made available in an accessible forma, a database-driven web window, for further use by infoDev, donors, experts and policy-makers. The production of a database-driven web window will cover essential materials across the range of aspects of health sector use of ICT identified in the research. In the case of a limited number of key unpublished materials, permission will be sought to make them available electronically. 2- Online consultation Following the established methodology for conducting successful online discussions the `ICT and Health ­ tracking information' discussion will be moderated and the questions designed to create a flow in the discussion over a period of three weeks; beginning more generally and then focusing on specific sub-themes. The choice of these themes will be informed by the preliminary research and may track with MDG themes. The discussion will be moderated daily and summarized weekly, with these weekly updates being shared on the d-group workspace, in order to encourage further engagement by participants. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 62 3- Framework paper The framework paper will draw on the information gathered during the process of mapping and dialogue/discussion to present analysis and make recommendations about priority issues related to ICT in the health sector. The paper will organize the issues and identify key questions, players and constraints. It will present an informed overview of ICT and health from a development perspective, and will identify good practice examples of the use of ICT in the health sector. It will also outline challenges facing the development of ICT implementation in health programs and activities, and identify the emerging trends and technologies that will shape ICT tools in the health sector. The analysis will be presented on an international and regional level, as well as on a country and community level according to the examples gleaned during the research phase. The paper will synthesise guidelines and good practices in broad terms for using ICT in the heath sector; it will focus on the cost-effectiveness of ICT supported activities, and the use of ICTs for better monitoring of health-related MDGs. Presentation of the research and the framework paper will be delivered in Washington DC in the form of a workshop, and in a variety of other formats including as an accessible electronic publication. This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 63 Appendix 3: Methodology Seven researchers based in the United Kingdom (UK), United States of America (USA), Kenya, Senegal, Australia and Colombia completed a broad search for relevant material. We searched a wide range of bibliographic databases and websites, conducted key informant interviews, and drew upon an international online consultation process to identify additional published or unpublished material. This was subsequently supplemented by the peer-review process for the framework paper, which helped to identify further relevant materials. Other outputs in the four month study have included the development of a fully searchable database of many of the most important materials on this topic, which it is hoped will prove to be a resource for policy makers and practitioners in the health and ICT sectors. Further outputs have included the conducting of an online discussion (summary available), and development of key lists of major themes and a literature review. All these outputs are available online at http://www.asksource.info/res_library/ict.htm. Where databases permitted the search strategy was adapted as appropriate to search the other electronic databases using subject headings. The full search strategy for EMBASE, MEDLINE, CINAHL, HMIC are available on request. Researchers selected material published since 2000 including material published 2000 to date and in particular looked for Bibliographies, mapping or scoping exercises, systematic reviews, research studies, review articles, policy discussions, case studies with wider policy implications or discussion of lessons learned. Individual case studies or descriptions of projects with no listed outcomes or wider implications were noted separately. no language restrictions were applied, although most databases or sources had English, Spanish or French language focus. Key words used in the search strategy included: Distance education (education, distance) Medical informatics Distance learning Personal digital assistant (PDA) Ehealth (e-health) Radio Electronic records Satellite Handheld compters (computers, handheld) Telehealth (tele-health) Health Telemedicine (tele-medicine) Health information technology Teleradiology (tele-radiology) Information and communication technology Videoconferencing For this Framework paper the following key words were used to further narrow the selection of articles. AIDS infectious disease Barriers malaria Child health maternal health Child mortality Millennium Development Goals childbirth Paediatrics (pediatrics) children Partnership. Donors philanthropy education policy environment poverty Gender Pregnancy global health sustainability HIV tuberculosis Hunger woman's health Material meeting the inclusion criteria was reviewed and bibliographic data entered onto an interactive database housed at the Source International Information Centre (see http://www.asksource.info/res_library/ict.htm. Keywords and abstracts were added to each record This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 64 which categorised the material according to taxonomy for ICT, Millennium Development Goals and WHO Public Health Functions. Emphasis for selection was placed on the following types of articles: 1. Published Articles from 2000 to date 2. Systematic Reviews 3. Peer reviewed Non-systematic Reviews published in reputable journals without comercial conflicts of interest 4. Randomized Controlled Trials 5. Non-randomized controlled trials with specific outcome indicators measured 6. Published International Agency and Government Policy Statements 7. Published Editorial and Opinion Based materials with policy implications List of sources Standard Databases: PubMed, EMBASE, CINAHL, PsycINFO, Health Management Information Consortium, LILACS, Scielo, Cochrane Database of Systematic Reviews, Database of Reviews of Effects, Cochrane Central Register of Controlled Trials, HTA, NHS EED, TRIP database, Current Contents, SUMsearch, Popline, ERIC, Web of Knowledge, Academic Search Premier, CISTI, TOC Premier, CISMeF, ELDIS. Non-standard database sources: (These were mainly identified through web sites) International Agencies: Development Gateway, ILO, ITU, FAO, UNAIDS, UNDP, UNESCO, UNFPA, UNICEF, UN ICT Task Force, UNIFEM, World Bank, WHO, WSIS Bilateral donor agencies: CIDA, Danida, DFID, DGIS, European Union, Norad, SDC, SIDA Trusts and Foundations: Dreyfus Health Foundation, Health on the Net Foundation, Hesperian Foundation Civil society organisations: AfriAfya, Africa Journals Online, AMREF, Arab Resource Collective (ARC), Asociación para el Progreso de las Comunicaciones (APC), Association for Health Information and Libraries in Africa (AHILA), BioMed Central, Bireme (Biblioteca virtual em saude), Child-to-Child Trust, Communication Initiative, Digital Dividend Project, Electronic Publishing Trust for Development (EPT), Engender Health, Exchange, Family Health International, Free for All, Gamos, Health Communication Materials Network (HCMN), Healthlink Worldwide, IDRC, IIDC, Indian Medlars, Interactive Health Network, INASP, International Health Impact Assessment Consortium (IMPACT), IPPF, ITDG, Media Materials Clearninghouse (MMC), NGO Networks for Health, OneWorld, PANOS, Partnerships in Health Information (Phi), PATH, Popuation Council, PubMed Central, Reproductive Health Gateway, Reproductive Health Outlook, SAInfo (South Africa), SatelLife, Scientists for Health and Research for Development (SHARED), Source, South African Medical Database (SAMED), Telemedicine Information Exchange, WWW Virtual Library This paper is part of a study commissioned by the infoDev program Grant no. 1254 ­ page 65