Hi Paul --

I totally agree that the potential of connected health technologies for improving life in the developing world is great. One effect they can have (as demonstrated by Operation Village Health) is enabling people to remain in rural areas and still receive care, rather than traveling or permanently moving to increasingly overburdened cities. This provides value both to individuals and to the environment.

The challenges associated with widespread use of such technologies in the developing world are in some ways not so different from those we face here--the hardest ones have nothing to do with technology. Among the big ones: money, politics, and education. As in the US, there are questions around the world about who should pay for health care, particularly when it is offered in an untraditional way (like remote telecare); appropriate incentives will need to be structured both for "reactive" and preventive care.

As far as politics are concerned, many countries (including China and Eritrea, to name a couple) have a distrust of or outright ban on certain types of information sharing, which certainly limits the use of resources like the Internet. Education, meanwhile, is of course a challenge in the US and beyond. If we assume that connected health technologies will enable consumers or patients to play a more active role in their own care, we have to present information in ways that are usable to very diverse populations--taking into account different languages, literacy levels, and cultural norms.

In short, while connected health technologies can in theory make information and services generally available around the globe, a lot of work remains to be done in facilitating their use on a local level--and I do hope many other countries will be more efficient at integrating them than we are in the US. Keep up the good work in Cambodia!

Hi,
Will do a more detailed post this weekend. However, quick contrib to the debate. ?Devil's advocate?

1. ICT in Medicine does not have to have anything to do with telemedicine. Apart from a few showcase examples, I do not think telemedicine has a huge role to play in any major form in developing countries ( I am loathe to using the term under-developed or third-world countries). E-learning may be a more relevant issue.

2. 'One effect they can have (as demonstrated by Operation Village Health) is enabling people to remain in rural areas and still receive care' - Again, telemedicine is not the answer. Training of health professionals working in these rural areas and capacity building is the answer. Transferring solutions developed for countries like US or UK seldom works in developing countries. Using telemedicine is only a small component of training health professionals and is not a solution in itself for delivery of patient care by any stretch.

3. I did not realise China had a ban on the internet!!! Yes it censors parts of it but then what country does not!

Again, shoot me down for my views - but the debate will be well worth it! More this weekend in reply to Paul's two questions.

I would support Vishnu's comment about the importance of capacity building and suggest that this is one of the key ways in which technology can help reduce the global burden of disease. An example is the Peoples-uni (http://peoples-uni.org) which develops educational context around Open Educational Resources for low-cost capacity building via the Internet. Partnership with excellent initiatives such as Operation Village Health and others which increase access to the Internet in a health context, will offer the opportunity to add value and help build capacity. Our area is Public Health and we would welcome any collaboration.

The healthcare system today is sick because it is doctor-centric. Healthcare is fragmented and disorganized and there are too many specialists , most of whom have tunnel vision.

In order to reform the healthcare ecosystem , we need to put patients at the center ! We believe that patients are the largest untapped healthcare resource !

Patients ( or their relatives and friends) are : intelligent and capable; and because they have a lot at stake , they are motivated to get good health care and will be willing to invest time and energy if given the right tools to ensure a good outcome.

We need to provide the tools directly to patients !

I feel there are 4 major influences which will help patients to regain control over their healthcare.

1. Patients will keep their own medical records using a PHR ( Personal Health Record)
2. Information Therapy can be precribed to them, tailored to their needs, based on their medical problems captured in the PHR
3. Web 2.0 technologies will allow them to form social communities to help and support each other
4. We can deliver this information to them 24/7 through their mobile, wherever thay maybe, whenever they need it !
Dr Aniruddha Malpani, MD
Medical Director
HELP - Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400001
Tel. No.:65952393/65952394
helplib@vsnl.com
www.healthlibrary.com

I came to this site via the IAMI googlegroup.

I work in a rural and semi-urban healthcare environment in India, developing clinical informatics solutions for rural populations.

Answers to your questions
1. How do you envision connected health technologies making an impact on the global burden of disease?

a) Communication. Mobile phones offer a direct communication resource between the people and healthcare workers, bypassing traditional pathways such as outpatient clinics. Also, the communication is in the people's own language, bypassing the need for translating and retranslating medical jargon.
b) Documentation. Traditional healthcare systems in the West are burdened by traditions of large paper record systems - often very little to do with patient care. Todays lean IT based documentation protocols, such as those we are developing for rural based healthcare in hub and spoke systems, mean little duplication and fast information sharing.
c) Data entry. Data entry processes in Western healthcare system are often combinations of non-integrated multiple legacy systems. In addition, the data entry clerks are experts at using these systems. Paradoxically, this means that archaic and complex data entry systems are perpetuated. We, on the other hand, make data entry systems for relatively inexperienced staff, who are not experts or fully educated, and whose only experience with computer programs are IM programs or, at the most, a web browser. Consequently, the systems we are developing are forced to be extremely simple in data entry which consequently makes them more robust and more easily learned by relatively less trained (and hence lower staffing costs).

Diffusion of these techniques upwards and downwards throughout the healthcare industry will improve data recording, business processes and ultimately speed up information exchange.

2. What do you perceive to be the biggest challenges to this vision?

a) Cost of IT hardware and software. We desperately need affordable hardware and software
b) Slow growth of fast broadband and mobile networks
c) Slow development of software in non-English languages

Regards

Manish Ghosh
Howrah India

Hello Everyone,
Thanks for starting up such a discussion on my passionate topic. ICT and health care. In the part of the world where i work and come from (Africa), ICT though seen as a tool to be used to improve health care delivery, but with very few experts available. Also the senior class at present who do not want yo learn new things and head organizations are not really interested in pushing for the adoption of ICT in health care. This frustrates the efforts of younger ones who have painstakingly studied what is going on in the developed world and are trying to align themselves towards this.
Along with Vishnu and the others i do not think Telemedicine is the point to start from when applying ICT in medicine. While working on my master thesis a few years back, i recount the difficulties i had in tracing case files of patients who had been seen in the health facility over a period of years.
Let me say that basic EMR's along with Health information systems are scarcely available in majority of countries in Sub-Saharan Africa. Thanks to the EU-Africa partnership which has produced softwares like the DHIS and the US/ WHO backed openmrs open source softwares. These softwares though becoming more available, there is still a scarcity of technical capacity.
So far in Nigeria, vertical programs supported by donor governments continue to enjoy near total health data gathering where routine health information systems are still yet to be exhumed from the archives where they have been long buried.
I will continue to use all avenues available to me to emphasize the importance of a routine health information system in Nigeria.

Thank you.
Olusesan Makinde
Jos, Nigeria

Thank you to those who’ve shared their thoughts so far... your shared insights have been very helpful for this discussion.

I would like to take an opportunity here to respond to Vishnu’s comments. I want to be clear that I am not proposing that telemedicine is “the answer” to all public health challenges in the developing world. I purposefully framed the questions around ICTs and connected health because of their broader scope. That being said, I do believe there is an appropriate place for telemedicine in the developing world when introduced collaboratively and thoughtfully. I will respond to Vishnu’s comments as numbered.

1) In my experience, telemedicine has functioned as a tool to facilitate capacity building. In our program, for example, we have observed that the local telemedicine-supported nurse at one site has increasingly become self-sufficient in patient management over time. This has been an informal observation, but we’ve also noted that the number of cases referred off site by the nurse has decreased over time. This suggests a greater degree of comfort managing the patients locally and independently. The capacity for experiential case-based learning through participation in actual patient care is something that telemedicine-based approaches inherently possess. (Consultants in our program have taken advantage of this opportunity and often include educational “pearls” and offer supportive feedback.) Perhaps the role in capacity building should be emphasized more deliberately, and the impact on clinical knowledge measured more rigorously to validate these proposed benefits.

I am also aware of instances in which mid-level health workers trained through conventional educational initiatives can pass standardized exams that measure knowledge, but lack the ability to make independent clinical decisions in real-life situations. All clinicians (health workers, nurses, doctors, specialists) and patients must know their own limits, and when to seek assistance from their colleagues. Telemedicine offers the option of a more collaborative team approach for those clinicians practicing in isolation. Due to significant shortages of health workers in the developing world, local collaboration is usually not possible. Networked ICTs can change that paradigm if clinicians welcome them into their everyday workflow.

2) As Lygeia notes, encounters between patients and healthcare providers from differing social and ethnic backgrounds are not uncommon and will only increase as migration and globalization continues to flatten the world. Your comments allude to the importance of cultural competence, and are I agree with your statement that transferring technologies and programs (i.e. e-learning, telemedicine, etc) designed for the US and UK will not work in developing world settings unless there is local ownership and leadership.

In summary, my proposed questions are not meant to focus narrowly on telemedicine but the broader scope of ICTs. I concur with Vishnu’s comments on the importance of ICTs for e-learning and capacity building. (I welcome additional thoughts from Vishnu to the second question I proposed “What do you perceive to be the biggest challenges to this vision?”) I am, however, less inclined to reject telemedicine outright and propose that there is a role for telemedicine as a tool in facilitating learning and capacity building in addition to its role in direct clinical care.

Hi Everyone --

I agree with Paul's response to Vishnu. Indeed I assumed we were discussing a much broader array of ICTs than just telemedicine -- though I do think it too can provide value, particularly when it is envisioned as strengthening and supporting a local team rather than beaming in expertise from outside to supplant local efforts.

On Vishu's third point -- I did not say that China has a "ban on the Internet;" I did say that certain types of information sharing are banned in some countries (including China). According to Reporters without Borders (http://www.rsf.org/rubrique.php3?id_rubrique=675), in 2007 there were 50 people in jail in China for posting criticisms of the government online. There are also numerous software filters and government agents who patrol web sites for "inappropriate" content and then block access to it.

Why does this matter in a health context? Often there's a fuzzy line between health and politics or religion. For one thing, filters--particularly those geared toward blocking pornography--may make it difficult to search for or discuss some symptoms or conditions. In addition, (and this comes from my observation in the small African nation of Eritrea, the other country I mentioned), some governments don't want their people discussing AIDs or other STDs (with which there is often a strong stigma attached), or conditions that might imply responsibility on the part of the government (failure to contain bird flu, illness resulting from pollution, etc.). And it's not just at the government level that people would like to restrict the flow of information. In many communities in African and Arab countries, for example, female genital mutilation is still common. My guess is those who practice it don't want women and girls--or men, for that matter, to have full access to information about its health and other implications.

A lack of open access to information makes it harder for patients and care providers alike to benefit from ICTs. All of which underscores the point that there are a lot of challenges in making sure that ICTs are indeed applicable and useful on a local level.

- Lygeia

What do you perceive to be the biggest challenges to this vision?

The Real Access/Real Impact Framework described by Bridges.org is fairly comprehensive and every point is worth a discussion in itself. There is no denying that huge challenges exist at every one of these levels.

http://www.bridges.org/Real_Access

(1) Physical access to technology
(2) Appropriateness of technology
(3) Affordability of technology and technology use
(4) Human capacity and training
(5) Locally relevant content, applications, and services
(6) Integration into daily routines
(7) Socio-cultural factors
(8) Trust in technology
(9) Local economic environment
(10) Macro-economic environment
(11) Legal and regulatory framework
(12) Political will and public support

Politics

"Also the senior class at present who do not want yo learn new things and head organizations are not really interested in pushing for the adoption of ICT in health care" - Olusesan Makinde

As much as I do not want this discussion to degenerate into a political one, the biggest challenge to widespread use of ICT for health care delivery as well as e-learning is political. In many developing countries, health is unfortunately not the most important priority of the government. Therefore, many top-down initiatives supported by developed nations do not necessarily have the expected impact. Yes, many African/Arab countries are 'behind time'. But, time is relative. It is vital to support them through their transition through the 'middle ages'.

It is also vital to acknowledge that large corporations (eg. pharmaceuticals) and institutions do not view these as viable markets that are worth investing R&D money in. (http://www.accessmed-msf.org/main/other-diseases/msf-and-neglected-diseases/) This is likely to be true for ICT as well. Political will both of developing and developed nations is the biggest challenge. (Me stating the obvious!!! Tired of scrolling within the comments box - will post another.)

About Telemedicine - one last time!!! (Ouch my head hurts, I think I may have been shot :-)

"I do think it too can provide value, particularly when it is envisioned as strengthening and supporting a local team rather than beaming in expertise from outside to supplant local efforts." - Lyegia

"Operation Village Health seeks to establish an innovative communications technology platform that increases local capacity and emphasizes effective, self-sufficient, and affordable local care for communities in the developing world."
-http://connected-health.org/programs/remote-consultations/center-for-connected-health-models-of-care/operation-village-health.aspx

As far as Telemedicine is concerned, my view is summed up by the above with which I entirely agree. I believe telemedicine is a small but vital component of ICT in healthcare delivery. Its role MUST be to train local health professionals rather than be a tool for patient care delivery in itself. Consultations over email and fora would be an essential part of health partnerships (see below). I would be keen to find out what this forum thinks about this project -( http://www.bridges.org/case_studies/352 ) in the context of decreasing global burden of disease.

Emergence

I am sure the concept of Emergence would be very appropriate for connected-health. While government - government links exist for the top-down approach to advise on policy, etc. it is vital for more hospitals and instituions in developed nations to facilitate partnerships with hospitals in developing countries. While a lot of work is being done already, imagine every hospital/NHS trust in the UK being linked up on a formal basis with a small group of hospitals/health centres in developing countries. These health partnerships ,working at a local level, will eventually change not only healthcare delivery at the national level but will also change how developed nations percieve the world. ICT is integral to maximising the potential of these health partnerships. Many small networked partnerships can then share their experiences/collaborate to achieve what the individual partnerships cannot. We are already beginning to do this in the UK.

E-learning and Leap-frogging

Has anybody put the $100 laptop to significant use in the health sector yet? As pointed out earlier in the discussion, the health care system in many developing nations suffer from a defeciency in both quantity and quality of health professionals.

Ethiopia, for instance, relies mainly on health officers and nurses working in remote health centres. Their training is short and inadequate. When they start work their inexperience coupled with professional isolation rapidly erodes their morale. ICT has a valuable role in supporting these health professionals by not only providing educational content but also by connecting them to urban hospitals/partner institutions abroad. We are currently piloting an e-learning program in selected health centres in Southern Ethiopia. Adopting e-learning would be a kind of leapfrogging in medical education for these nations.

Open Content - BIG CHALLENGE

A lot of money is spent on developing technology and content for use in developing nations by many hundreds of NGOs. Releasing these under more open licenses (e.g. CC or even Open Access) will not only increase dissemination of such electronic content but will make content creation easier and cheaper. And, yes there will be questions on reliability of such open content. And, no, I do not have any answers...yet. Primary Surgery (www.primary-surgery.org) is one example.

Such content made available within a learning management system makes administration and monitoring of usage much easier.

Patient Education

ICT can play a more important role in patient education. Few things are more engrossing than the 'idiot-box'. Anybody disagreeing with this would automatically assign themselves to an older generation or the minority that have access but choose not to fall into the trap. [http://www.sciam.com/article.cfm?id=0005339B-A694-1CC5-B4A8809EC588EEDF] I was thrilled to see about 50 patients watching a video made by an NGO called Safe Hands for Mothers (www.safehands.org) at a health centre in Wondo-Genet in Ethiopia. The television is a powerful medium to disseminate health information. Once again de-restricting content would aid in dissemination. For instance, in this case, the video was in Amharic. Releasing the video under a CC license would have allowed an NGO in Sudan to dubb it in Arabic, maybe.

Is there or should there be a central repository of shareable (open) content (that almost reads SCORM!) that can be used by health organisations working in developing nations without fear of copyright infringement?

Hi everyone,

Thanks Paul for starting this interesting discussion. I want to share a bit of what my organization AfriAfya ( African Network for Health Knowledge Management and Communication) has been doing with health and ICTs. We have in the last seven years implemented program activities that sought to leverage the potential of ICTs to increase access to community health information in rural Kenyan settings.

AfriAfya works as a coordinating hub for resource centres in existing facilities that are run by our Partner Agencies. Each of these sites is equipped with ICT equipment, local staff trained in their use, and a two-way communication system with the AfriAfya Hub established. The hub collects, synthesises, adapts and disseminates information to local change agents trained to combine modern and traditional means of spreading information ‘beyond the computer’ to their communities for social transformation. HIV/AIDS was used as the pathfinder topic since it is of high interest in Kenya. AfriAfya has now expanded to cover other health and development topics of interest to the communities. Through this, we have implemented program 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 all types of health information as well as development information.

Since inception, AfriAfya has strived to work with vulnerable communities to avail appropriate, relevant and up to date information that they can translate to knowledge to better their lives. Through this approach, a wide variety of relevant health and other development information have been made available to participating communities. We currently have 34 self-sustaining resource centers spread all over Kenya and another 4 in Somalia. All these have been set up with support from our partner agencies and donors. Each of the centers is equipped with a computer, a printer, a television, a video player, a digital camera, an audio tape recorder, a mobile phone and a World Space receiver. Majority of the sites are in areas where there is no electricity. This bottleneck in running the resource centers has been overcome by the use of solar power technology, a practical alternative in Kenya, a country that straddles the equator.

We have trained over 1200 people and received and responded to over 300 information requests. We have detailed information on almost 200 different topics in our database which has been repackaged and tailored made for communities. Information is delivered to the target audiences through different methods both print and electronic media. At the resource center level, audio-visual and oral communication by way of talks, songs, drama and poetry are used to take the information to the community members. The use of this information has led to improved health and socio-economic status of the communities we work with.

One of the key pillars of AfriAfya’s work is the capacity building of community own resource persons or change agents so that they are empowered to identify and collect health and development information requests and disseminate appropriate information that meet their communities’ needs.

Categories of community change agents that we work with include healthcare workers, community health workers, teachers, outreach workers, traditional healers, community leaders, women’s group leaders and youth leaders. These change agents act as catalysts for generating local and indigenous knowledge within their communities. The training we give them enables them to utilize the available ICTs to collect, repackage and disseminate both local and global information to their communities.

It is therefore possible to use ICTs in rural and marginalized areas and have a positive impact. One just needs to be innovative and willing to try new things. We have succeeded in doing this despite numerous challenges. You can visit our website (www.afriafya.org) for more information.

Regards,

Dr Koki Muli-Kinagwi
Ag Director, AfriAfya
Email: kkinagwi@afriafya.org
www.afriafya.org

Paul thanks for setting up this important discussion on Connected Health in the Developing World.

I am just drawing attention to
1. Our research group in this area "Health Informatics in Developing Countries"
http://www.hein.otago.ac.nz/index.php?cat=research&page=hidc

2. A journal in this area "Journal of Health Informatics in Developing Countries"
http://www.jhidc.org

Thanks
Alec

Alec Holt - http://www.business.otago.ac.nz/infosci/People/Staff/aholt
Director of the Health Informatics Program

Health Informatics site - http://www.hein.otago.ac.nz

Senior Lecturer
Department of Information Science
University of Otago
PO Box 56
Dunedin 9054
New Zealand
Tel +64 3 479 5032 Fax +64 3 479 8311

Hi Paul

I have enjoyed reading all the replies so far on this interesting topic.
I am a technologist and business person and therefore may provide a different view.

How do you envision connected health technologies making an impact on the global burden of disease?

First of all, as I see it, the earth is a developing world. Granted there are parts of the overall population (demographics) that have greater issues than others pertaining to medical needs.
I envision an infrastructure where expertise is available to help anyone in need at any time. The question is; how do we connect them quickly? In addition, rapid access to information for diagnosing and supporting patients is critical. I believe that constructing a global communications network and tearing down political and cultural barriers to providing healthcare will be necessary.
I have worked with eLearning systems in the past and agree they are an excellent method for educating physicians as well as patients. eLearning is one of many modalities that a robust network infrastructure can transport throughout the world. The future will be bright if this transport infrastructure is in place given the direction of groups like Continua who are bringing about a myriad of small devices to monitor patients and report their vitals electronically
.
What do you perceive to be the biggest challenges to this vision?

The greatest challenge to this vision will be to architect a communications facility to connect with patients and transport information in all of its forms (data, voice, video) to all parts of the world. This is not as much a technological challenge (given today’s communications technologies) as it is a political one. This can best be accomplished through government involvement as well as national and international standards organizations. If you are a nation that doesn’t play in the international standards arena, you run the risk of being exposed to the world as a maverick. Consider that the internet evolved from the need to interconnect universities, military, and businesses to work collaboratively for achieving goals. This approach fostered national and international standards which now allow us to communicate and collaborate throughout much of the world.

I hope this is a useful perspective.

Best wishes