88229 ICTs for health in Africa eTransform AFRICA AFRICAN UNION This document, on the use of ICTs for Health in Africa, was prepared by Meera Shekar of the World Bank and Kate Otto (consultant). It is a summary of the full sector study which was carr ied out by a team from Vital Wave Consulting led by Nam Mokwunye and supported by Bethany Murphy, Rick Doerr and Brendan Smith. The full report is available at www.eTransformAfrica.org. This document forms chapter six of the publi- cation edited by Enock Yonazi, Tim Kelly, Naomi Halewood and Colin Blackman (2012) “eTransform Africa: The Transformational Use of ICTs in Africa.” Funding for the publication came from the AfDB Korean Trust Fund, the WB Pfizer Trust Fund and the WB Africa regional department. eTransform AFRICA AFRICAN UNION ICTs for health in Africa Information and communication technologies (ICTs) have the potential to transform business and government in Africa, driving entrepreneurship, innovation and economic growth. A new flagship report – eTransform Africa – produced by the World Bank and the African Development Bank, with the support of the African Union, identifies best practice in the use of ICTs in key sectors of the African economy. Under the theme “Transformation-Ready”, the growing contribution of ICTs to Agriculture, Climate Change Adaptation, Education, Financial Services, Government Services and Health is explored. In addition, the report highlights the role of ICTs in enhancing African regional trade and integration as well as the need to build a competitive ICT industry to promote innovation, job creation and the export potential of African companies. introduction ICTs for health in Africa 1 � Trends and challenges  p3 � ICT as a game changer in health p5 3 Countries in Africa spend significant the health sector in a systematic way. amounts of their GDP on delivering Although there are many ongoing health services through systems that projects across Africa that attempt are often inefficient, costly and lacking to improve the health sector through in transparency. Information and com- the use of ICTs, most remain pilots, munication technologies (ICTs) have few are evaluated and even fewer are the potential to transform the delivery designed or assessed for scalability. of health services across the continent While a recent World Bank survey of in ways that not only increase efficiency nearly 150 active health projects re- but also improve accountability (World vealed that a third had a specifically Bank, 2004). financed eHealth component, few were systemic fixes, and a gap remains in The availability and quality of ICT ser- strategy, communication, capacity and vices are growing rapidly across Africa, available investment regarding ICTs for with mobile network coverage rising health system strengthening. from 16% in the late 1990s to over 90% of its population in 2011. Growth ICTs present a large, unexploited po- in this sector has led to increased in- tential for transforming governance vestments, decreased costs and rapid and transparency in the health sector growth in technology-enabled services. in Africa to achieve “more health for money spent” and thereby improve the However, these gains in ICT infra- efficiency of health spending, both do- structure have not as yet benefitted mestic- and donor-financed. Trends and challenges The overall trend in healthcare across (SSA) has experienced a reduction in Africa reflects the optimism aris- child mortality from 180 to 129 deaths ing from the general improvement per 1,000 live births, and while there in social welfare, as shown by the is still regional progress to be made 10 percentage-point reduction of to reach the MDG goal of 60 by 2015, people living on less than $1.25 per certain countries with high under-five day between 1999 and 2009. While mortality, like Madagascar, Malawi, few African countries are en route to Eritrea, Liberia, Niger, and Tanzania, achieving the health-related Millen- have already more than halved their nium Development Goals (MDGs), rates of child mortality between 1990 many are making significant progress. and 2010. Similarly, while the en- For instance, sub-Saharan Africa tire region requires more progress to 4 reducing maternal mortality by three- poor quality of care delivered in the quarters by 2015, Equatorial Guinea, absence of training and knowledge Eritrea, Cape Verde, Ethiopia, Rwanda, support in the field. and Mauritius have already more than halved their rates since 1990. Progress • Lack of health information systems: on MDG 6 is also visible in countries Many low- and middle-income like Botswana, Rwanda, Namibia, and health systems lack sufficient tech- Zambia, where over 55% of people liv- nology to enable communication ing with advanced HIV have access to between households, care provid- antiretroviral therapy. ers, and eventually, policy makers. The absence of these infrastructure Although immense progress has been elements increases the possibility made, a majority of Africa countries of morbidity and mortality owing are falling behind on their MDG com- to the “third delay”, i.e. the delay in mitments and existing strategies will receiving adequate service after reach- not be sufficient. New approaches are ing a healthcare facility. The impact needed. is felt most by people in rural areas, where delays are more extreme. The main opportunities for ICTs to positively impact the health sector re- • Shortages of drugs, equipment and flect the remaining core challenges supplies: Without medical equip- countries face in pursuit of MDG tar- ment and supplies it is difficult for gets, and implementation of ICTs to as- health workers to provide the care sist in resolving micro-level challenges they have been trained to provide. will only be successful if macro-chal- Sometimes, supply shortages even lenges do not obstruct ICT capabilities. lead to health centre shutdowns. The systemic challenges faced are sub- In 2010 in Uganda, for example, stantial and complex, and include: eight rural health centres closed because of lack of supplies, leaving • Insufficient skilled healthcare work- people in the Amuru district without ers: It is estimated that Africa, which healthcare, and an additional twelve has 11% of the world’s population, recently-built health centres have carries 22% of the global disease bur- not opened for the same reason. den and more than 1.5 million addi- tional health workers are needed to • Inadequate public informa- resolve the human resource short- tion about preventable diseases: age. Yet in resource-constrained The simplest preventive solutions health systems, existing workers are can lead to lives saved. For example, often inefficiently allocated, leaving while HIV testing services may be service gaps in rural areas, or insuf- highly available, without encour- ficiently monitored and motivated, agement and clear communication leading to attrition and potentially about the details of the service they 5 may go underutilized. Or alterna- • Financing constraints: Often, care tively, if the general public was able to is not accessed because patients are receive information about contami- unable to pay out of pocket. Also, nated water sources – in the form governments remain challenged to of alerts about diarrhoea or malaria provide adequate financial resources outbreaks – households could protect for seeding health systems infra- themselves from disease. structure, research and innovations. ICT as a game changer in health eHealth may be defined as the use of extend services to underserved areas, information and communication tech- and reduce waste and redundancy. nology (ICT) – including computers, mobile phones, satellites, software, Data from the 2011 Global Observa- information systems and digital plat- tory for eHealth (GOe) survey showed forms, etc – to enable, support and that some 83 per cent of 112 surveyed deliver health services to patients and countries identified at least one ongo- populations. eHealth can make use of ing mHealth programme, and 33 per tools like mobile phone-based health cent identified at least one telemedicine (mHealth) applications, telemedicine programme within their country. Of systems, or eLearning programmes, the 31 African countries who respond- and includes the digitization of a coun- ed to the survey, SSA nations were least try’s Health Management Information likely to have established, institutional- System (HMIS) or Health Information ized eHealth programmes in mHealth, System (HIS). It is assumed that use of telemedicine or eLearning. When these ICTs will lead to greater efficiencies in programmes exist, they are in either use of resources and greater efficiency the pilot or informal stages of devel- in service delivery, a significant mat- opment. Yet the fact that over 67 per ter when the 2010 WHO World Health cent of the African WHO members re- Report revealed that 20 to 40 per cent sponded to the survey is encouraging, of all health spending was wasted due indicating willingness to “mainstream” to inefficiencies. Investment in ICT has eHealth as a component of their health the potential to reform health systems, strategies. landscape analysis ICTs for health in Africa 2 � eLearning and tele- medicine p7 � Data exchange and analysis p8 � Supply chain manage- ment p9 � Public health promo- tion p10 � Health financing p10 7 Though limited in quantity and rigour, including programmes for tracking there is evidence emerging that ICTs patient records, monitoring infectious can address challenges of maternal and diseases, managing drug and supply child health and infectious diseases in chains, telemedicine communications rural Africa. Hundreds of mHealth in- with health professionals in distant terventions to date have been piloted areas and eLearning and training for across the continent, for a variety of healthcare workers. With the proper purposes including remote consulta- telecommunications infrastructure and tion, patient data management, refer- committed leadership, such strategies rals, supply chain management and could facilitate new business and ser- health worker training. Some countries, vice models. For this reason, countries like Rwanda, have implemented a com- are experimenting with different types prehensive national eHealth System, of applications, as outlined below. eLearning and telemedicine eLearning and telemedicine pro- and between the country’s thirteen tele- grammes have the capacity to improve radiology centres, three tele-pathology, human resources for health by enabling two tele-optomology, six regional hos- workers with the training and informa- pitals, general hospitals and six special- tion, needed to respond to emergen- ized centres, up to twenty remote sites cies and crises. Several Francophone can utilize the videoconference at any African countries, such as Mali, Cote given time. d’Ivoire, Senegal and Burkina-Faso, have implemented an online platform Other programmes targeting commu- (RAFT) that allows for web-based sem- nity health workers include Botswana’s inars, training, discussions and sharing eLearning programme for community of best practices between healthcare health workers at the KITSO AIDS professionals in each of the ten par- Training Program, a public-private ticipating Francophone countries. The partnership between the Ministry of Tunisian Society of Telemedicine and Health and Harvard Medical School. eHealth – an NGO composed of doc- Other innovative forms of support for tors, telecom engineers, and commu- frontline health workers are applica- nications specialists – sponsors and tions like CommCare, from mHealth promotes videoconferencing between company Dimagi, which programmes health professionals in emergency various health worker protocols for dif- cases. It allows for tele-diagnosis by ferent types of patient interactions into professionals in hospitals at a distance, a mobile phone, complete with picture 8 and voice prompts for not fully liter- Such simple interventions could make ate users. Other creative ICT solutions a significant difference in attracting, for the human resource crisis include retaining and improving the perfor- Switchboard’s MDNet programme, a mance of limited health workers, like free closed calling network between using mobile phone communication all doctors’ mobile phones in Ghana, to improve referral systems, or creating which removes the cost and connectiv- an interactive voice response menu on ity barriers to doctors seeking advice or a phone that contains knowledge re- assistance from their peers. minders and remote training for health workers in rural locations. Data exchange and analysis In traditional paper-based reporting provides a lightweight, user-friendly systems, collecting and exchanging option for an electronic medical re- quality and timely health data re- cords system. mains a challenge, as the process can consume the time and attention of A unique feature of ICT-enabled data health workers who are meant to be collection is that data can be viewed providing services instead, and can and analysed in real time so that care result in inaccurate or incomplete providers and policy makers can data. Electronic Health Information make lifesaving decisions based on Systems (HIS) can help minimize evidence. Such tools can save health time spent recording data, such as the workers time and costs of paper- HIS shared across Southern African based data entry and transportation, countries Botswana, South Africa, as in a project in Guatemala when the Mozambique, Ethiopia, Malawi and World Bank reported a 71% decrease Tanzania. The BEANISH programme in data collection costs when using – Building Europe-Africa Collab- the programme Episurveyor on a mo- orative Network for Applying ICT in bile phone for data collection com- Healthcare Sector – is an open-source pared to paper. When the NGO Part- Java-based program that allows health- ners in Health employed a personal care professionals to gather data digital assistant (PDA) for tubercu- and enter it into a digital healthcare losis results collection, the process- system, which can be used for data ing time of 6.2 days was significantly analysis and management. Similarly, lower than baseline and control days OpenMRS, developed by the Regien- with date entry errors reducing from strief Institute and Partners in Health, 10.1% to 2.8%. 9 When designed appropriately, free help Ghana achieve those goals. Using and customizable software like Episur- General Packet Radio Service (GPRS), veyor, OpenXData and Open Data Kit Short Message Service (SMS) and In- enable remote fast, accurate and inex- teractive Voice Response (IVR) tech- pensive data collection eliminating a nologies, MoTeCH surveys midwives, large amount of burdensome work that allows them to dial-in toll-free and distracts workers from their core du- record and update critical data about ties. The Mobile Technology for Com- pregnant mothers. Another example, munity Health (MoTeCH) Midwife Child Count, is an SMS-based appli- initiative, for example, conceived by cation that allows community health the Grameen Foundation and funded workers to upload patient metrics to an by the Bill & Melinda Gates Founda- external database which is then moni- tion, uses mobile phone technologies to tored for irregularities. Supply chain management Weak supply chain systems across low- mechanisms to track counterfeit drugs income countries – caused by poor in developing countries. road infrastructure that delays delivery, and poor electrification that eliminates The World Bank is currently conduct- the possibility of a cold chain – can ing an evaluation in Zambia of the use result in remote health posts being of mobile phones to improve supply under-stocked or stocked-out of essen- chain management. Other ongoing ef- tial commodities, such as contracep- forts include StopStockouts, in Kenya, tives for reproductive-aged women and which allows field-level health workers vaccinations for children. Further, the to report stock-outs by SMS on their World Health Organization’s estimate mobile phones to a central database that 10-30% of drugs in the developing which then converts, via GPS data, world are counterfeit could put mil- to a geographic visualization of the lions of lives on the African continent problem in order to alert adminis- at risk of unnecessary death and disease trators and supervisors of the issue. if those medicines make it into the sys- In Tanzania, the SMS for Health proj- tem unnoticed. In Ghana, mPedigree ect uses ICTs for supply chain manage- employs Sproxil, a technology that uses ment of malaria drugs. barcodes and unique identification 10 Public health promotion An AED-SATELLIFE project, the Aside from surveying public infor- Uganda Health Information Network mation for use by the government, (UHIN) uses PDAs to provide early there are many ICT for health efforts warning information about the spread that aim to deliver key public health of communicable diseases to citizens. messages from the government to The data collection element is four the public. Launched to encourage times as efficient and 25 per cent more healthier behaviour that avoids future cost effective than manual data entry, treatment costs, Praekelt Foundation’s with the goal of surveying popula- Project Masiluleke, a programme that tions for crucial disease information. offers free information about HIV With the ability of mobile phones to testing locations via customers’ mo- track and record GPS locations, gov- bile phones, resulted in 1.5 million ernments can be more informed about calls to a local AIDS helpline. Mobile emergency disaster relief scenarios. phones are also being used in Uganda RapidSMS, InSTEDD’s GeoChat, and in the Text to Change campaign, Ushahidi are all applications that have which seeks to increase knowledge been used to assist governments with and understanding of HIV/AIDS rapid response to emergencies from through SMS-based quizzes. famine to flooding to earthquakes. Health financing Patients often forego care owing to the allow even low-income people to man- inability to pay healthcare costs out age small payments from their mobile of pocket, and providers and health phone without requiring a bank ac- system administrators are struggling count. Programmes like Changamka in to make care truly accessible in low- Kenya provide patients with pre-paid resource environments. Considering “smart cards” coded to approve them that, by the year 2012, there will be an to receive specific kinds of healthcare estimated 1.7 billion people with no at designated health facilities, and can bank account but who own a mobile be topped up by M-PESA or at physical phone, the proliferation of mobile mon- terminals. The opportunities for per- ey systems like M-PESA in Kenya is an sonal finance to strengthen health sys- emerging ICT solution. Such services tems are numerous since both require 11 components like user IDs, identity Table 1 summarizes the opportuni- authentication and security measures. ties for ICT interventions to address By enabling patients to set aside funds the major challenge areas listed above. for health specifically, and make more Yet it also indicates that such interven- direct payments, efficient delivery of tions cannot be realized without ad- health services becomes quicker and equate infrastructure and committed more cost-effective. leadership. Table 1 Summary of opportunities and challenges for ICT to improve health systems Health Sector ICT Opportunity ICT Challenge Challenge eLearning and telemedicine solutions can extend Facility set-up and maintenance costs and efforts; Insufficient skilled expertise to remote areas and provide otherwise sufficient will for providers to participate (liability healthcare workers inaccessible care. concerns). Data collection and surveillance mHealth applica- tions can monitor and track health indicators in Requires widespread mobile connectivity and Lack of health real time, providing insight to policymakers on true sufficient access to phone hardware, but not information systems challenges and providing valuable data enabling always the case. health workers to better serve and patients to be more proactive in their own health. To realize full potential, ICT solutions still rely on Supply Chain Management mHealth applications Shortage of drugs, physical transport of goods and services. If entire can decrease stock-out frequency and increase equipment and supplies system poorly organized, digitizing system likely efficacy of and trust in health system. will not help. Public health promotion applications can be To be successful, ICT solution still relies on end Inadequate public used to disseminate empowering information in user to take action on information, and assumes information about friendly, personal manner. Engaging without being health system is prepared to handle increased preventable diseases intrusive. patient load. Participation in mobile savings programmes Health financing and personal insurance still requires commitment from users. Also, Financing constraints programmes offer increased opportunities for sav- governments still are challenged to commit more ings, both for patients and healthcare providers. significantly to health systems. case studies ICTs for health in Africa 3 13 Several countries, including Ethiopia within the framework outlined above and Mali, have made notable advances to identify their micro and macro chal- in utilizing ICT to increase health- lenges, and to investigate key eHealth care access and quality of service to interventions that have gained traction their populations. Ethiopia and Mali within each country. were analysed as case study countries Box 1 Lessons from Ethiopia Ethiopia’s health sector challenges reach of services provided via ICT range from the macro-level con- solutions, while expending fewer in- cerns of funding, human capital, cremental resources. infrastructure and cultural norms to specific health-sector challenges One example is the application of such as equipment and supply ICT to supply chain management, shortages, insufficient quantity of specifically through the DELIVER skilled healthcare workers, and a rel- PROJECT which began in 2003. The atively uneducated population. Over FMOH, USAID, and other develop- the past six years, the Ethiopian ment partners implemented the government has rolled out signifi- Logistics Management Information cant national telecommunications System (LMIS) in order to ensure the infrastructure. This has enabled the availability of vital health supplies. Federal Ministry of Health (FMOH) to DELIVER ensured efficient deliv- use ICT to improve data exchange ery systems, transparent and cost- within hospitals and to support the effective procurement processes national cadre of Health Extension and strong supply chains that worked Workers (HEWs) in remote areas. both domestically and internation- ally. Two crucial projects followed Integrate efforts and look for DELIVER, interoperating with its sys- synergies tem: the Improving Supply Chains for Community Case Management The FMOH began the process of of Pneumonia and Other Common integrating all ICT solutions in the Diseases of Childhood (SC4CCM) health sector by commissioning a project, focusing on improving sup- strategic framework for delivering ply chain management at a local eHealth and mHealth interventions level in order to improve the treat- to the population. Though they have ment of children under five; and the yet to implement the strategy, dis- Supply Chain Management System cussions from within FMOH indi- (SCMS) focusing on procuring and cated that all stakeholders value the distributing medicines and supplies increased efficiency and expanded needed for HIV/AIDS patients. 14 Refine underlying systemic and allowing France Telecom to man- organizational processes age Ethio Telecom. Ethiopia’s FMOH also demonstrated HEWs and ICT in Ethiopia: oppor- the ability to refine the underlying tunities and challenges systemic and organizational pro- cesses that control operations in Opportunities the health system before attempt- • Utilize telemedicine to connect ing ICT interventions. This approach HEWs to the appropriate health is exemplified by their HIS reform, personnel in order to receive as- during which the FMOH and all sistance in diagnosing and refer- partners undertook a painstaking ring patients. reorganization of the paper data collection system before introduc- • Leverage ICTs to allow for the ing electronic capture and transmis- continued training of HEWs while sion of data. Through this process, they are still in the field. Ethiopia recognized that even ad- vanced technology overlaying faulty • Use mobile applications to ef- processes is unlikely to deliver im- ficiently collect patient data and provements in health system func- keep longitudinal records. tioning or service delivery. Challenges In applying ICT to solve health • Large volume of HEWs to train systems problems, Ethiopia has and provide phones for (30,000). been most effective at national- level initiatives, such supporting • Language barriers in written in- the Health Extension Programme formation. (HEP), through which all HEWs are employed, with ICT tools, and • Technology limitations on the building private-sector participa- quantity of information that can tion with the ICT sector, such as be delivered. 15 Box 2 Lessons from Mali Mali provides an example of a low- funding and ICT options. Some of income country with extraordinary these programmes, such as the health challenges that has acknowl- adoption of an e-administration edged the value of ICT and is at- system, are government initiatives. tempting to expand its technologi- Others, such as Pesinet, have been cal capacity on a limited healthcare developed by NGOs with the approv- budget. Mali has recently adopted al and potential future involvement many of the recommended short- of the government, within a public- term interventions in the fields of private partnership framework. telemedicine, distance learning, The Flotte de Mobile programme remote data collection and health- is the result of such a partnership care worker communication. that involves the Ministry of Health, the mHealth Alliance, the Orange Use ICT to realize efficiency and Foundation and the Rockefeller combat waste Foundation. Similarly, IKON Tele- radiology and Keneya Blown grew Telemedicine is being used to out of partnerships between an NGO overcome the lack of trained (IICD) and groups of Malian medical healthcare workers and specialists professionals. These programmes in rural areas, specifically the IKON illustrate how the private healthcare Tele-radiology programme, and digi- sector can optimize local resources tal distance learning tools are being through coordinated efforts with used to improve healthcare worker government. The decentralized na- training and efficacy, such as the ture of the country also allows re- RAFT network, CATEL and Keneya gional and community healthcare Blown. Further, open-source digital centres to independently experi- medical record systems are being ment with interventions, creating an used to develop e-administration environment conducive to innova- systems, further improving efficien- tion and partnerships. cy and combating waste. The up- coming Flotte de Mobile programme Growth strategy will further improve healthcare work- er communication and allow for Though it has made some promising remote data collection. steps toward a more comprehensive eHealth programme, Mali would Partnerships increase access to benefit from adopting more appro- expertise, funding and ICT priate ICT interventions and pro- grammes. A mobile-assisted supply The programmes in Mali result chain management system would be from a wide range of partnerships useful to prevent waste and stock- which increase access to expertise, outs and improve management 16 of medications, immunizations Mali’s communication infrastruc- and insecticide-treated bed nets. ture: opportunities and challenges Given the lack of access to finan- cial services and insurance, Malians Opportunities would benefit from mobile-based • Communication between rural savings and insurance programmes and urban areas can be further that could be used for basic and developed by strengthening tele- emergency health needs. ICT-based health programmes, the e-admi­ public information campaigns such nistration intranet, and various as radio shows, information hot- practitioner networks including lines and mobile-recorded mes- RAFT, Keneya Blown and CATEL. sages about preventable diseases and healthy practices for expect- • Additionally, the use of data col- ant mothers and children could lection software packages such vastly improve health education as DHIS2 and OpenClinic should and help reduce mortality rates. better facilitate the exchange of In the long term, Mali will need to information and data between ru- address many of the country’s sys- ral and urban centres. temic challenges, including improv- ing rural connectivity, roads and Challenges healthcare infrastructure, and train- • Limited internet connectivity. ing capacity. • Weak infrastructure, particularly electricity in rural areas. recommendations ICTs for health in Africa 4 � Recommendations for policy makers, regulators, administrators and project managers p18 � Recommendations for donors p23 18 The degree to which an eHealth ser- A strong, enabling environment in- vice can be effectively established and cludes scalable and appropriate infra- provided is often dependent on the structure, transparent processes, fair complexity of the system being imple- legal frameworks, rules and standards mented in relation to the enabling in- for ICT component interoperability country environment. Yet, for many and incentivizing policies. The success countries, eHealth interventions are of interventions could be accelerated generally neither systematic nor fully through stakeholder collaboration in- strategic. Typically, there is a lack of volving end-users, government (cross- emphasis on: sector), civil society (including donors), private sector (industry) and research- 1. Infrastructure and standards: creat- ers, and a well-designed mix of ICT in- ing an enabling environment, terventions could help a country create synergies and avoid redundancies. The 2. Partnerships: amplifying collaboration resulting product would improve re- between critical stakeholders, and source allocation, reduce delays to care, improve continuity of care, improve 3. Interoperability: exploring effective health worker skills and make ICT use- combinations of interventions. ful to health workers as a tool for over- coming the challenges discussed earlier. Recommendations for policy makers, regulators, administrators and project managers The recommendations listed below will • Implement interventions that pro- help those who participate in and influ- duce measurable results. ence the delivery of ICT-based health solutions in Africa to: • Evaluate the impact and cost-efficiency of ICT solutions before going to scale. • Design appropriate and sustainable ICT solutions for health systems • Develop fast-track options for multi- strengthening efforts. country collaborations. 19 Recommendation 1 Create specific and scalable architecture A scalable architecture should be eHealth ecosystem becoming more established to assure an eHealth sys- common in Africa is ongoing in tem can expand to meet new capacity Sierra Leone. requirements, adapt to social or polit- ical changes and continue to function With a multi-phased approach to tar- despite financial limitations. One get specific segments of the healthcare useful reference model is the mHealth community, administrators can con- Alliance’s Enterprise Architecture sider the needs, situation and infra- initiative (see Box 3), coordinating all structure of the country to optimize stakeholders, including consumers, intervention and cost. It is important administrators, application develop- to aim for simple, low-cost interven- ers, vendors, policy makers, regula- tions before attempting more complex tors, civil society and funders. System system-based interventions that inter- rules provide boundaries that govern act with other health technology ini- stakeholders’ use of health systems tiatives. The more ICT is a part of the and the platforms on which they healthcare worker’s daily engagement, are managed, allowing developers, the more likely eHealth interventions in particular, to create appropriate will become accepted as the norm. applications. Another example of an Box 3 next page l Recommendation 2 Precede ICT interventions with needs assessments Before large-scale investments in to support ICT-based interventions, eHealth are undertaken, policy makers including physical infrastructure, hu- should commission a comprehensive man capacity and telecommunications needs assessment to provide an up-to- networks. Similarly, an infrastruc- date, objective view of the health and ture asset assessment will ensure that intervention needs of the population eHealth strategies and interventions and of health workers. An additional properly leverage existing and available situational analysis can also provide an infrastructure, and that policy makers examination of the resources available map evidence-based interventions. 20 Box 3 The mHealth Alliance’s Enterprise Architecture Initiative The mHealth Alliance is working With its partners, the mHA is devel- with a wide variety of organiza- oping a draft enterprise architecture tions to create a coordinated, flex- as a first reference model – initially ible, global collaborative team able to be deployed in South Africa – to support leaders from developing so that the various stakeholders countries in: can see the benefits of such a sys- tem and test various collections of • Developing requirements, software and services. The diagram below is a depiction of what the • Designing systems that addresses “info structure” might look like for those requirements, a system with an Electronic Health • Deploying first reference models, Record (EHR), repository for labora- • Learning from mistakes and suc- tory data and core services, authori- cesses, and zation/access control. • Continuing a process of rapid pro- totyping and spiral development Health EHR Laboratory Registries Information Data & Data & Data & Data Services Services Organizations Warehouse Core services Health Information Access Layer Message Bus (Wired and Wireless) Point of Service Point of Service Application Application 21 Recommendation 3 Create fora to unite decision-makers National governments should facilitate One example of this type of forum is cross-sector dialogue and cooperation “Connect Africa”, a working group con- by creating forums in which public and vened by the African Union and Inter- private-sector decision makers can col- national Telecommunication Union, in laboratively determine priorities and partnership with the World Bank, gov- identify available assets, reducing frag- ernments of donor countries, and gov- mentation and accelerating the poten- ernments of participating African coun- tial for scale. A well-executed forum tries. Launched in October 2007 with allows diverse stakeholders to share USD $55 billion pledged at that time, best practices and capitalize on econo- the initiative is designed to mobilize all mies of scale, even through regional resources needed to bridge ICT infra- collaborations. Regional Economic structure gaps across Africa. In such a Communities (RECs), supported by regional forum, economies of scale can the African Union, World Bank, In- easily be derived; for example, the suc- ternational Finance Corporation (IFC) cess of UNICEF’s rollout of RapidSMS and African Development Bank, could to improve supply chain management also play a role in bringing decision during the famine in Ethiopia could be makers together. replicated in similar situations in other countries, such as Somalia. Recommendation 4 Create incentives for partnership and foster cross-sector collaboration Development of ICT-based solutions discipline and deep understanding of tends to be “siloed”, within a vertical consumer needs. sectors, yet the multi-faceted nature of eHealth requires the skills and re- Creating a cross-sector digital platform sources of multiple sectors. National with potential use across health, finan- policy makers can facilitate multi- cial services, agriculture, public services sector partnerships that include and education could accelerate the the private sector, universities and scaling and sustainability of ICT-based other research and development or- interventions by increasing econo- ganizations. Public-private partner- mies of scale and return on invest- ships can encourage corporate fiscal ment. This is particularly important in 22 African countries that are small mar- countries, mobile platforms that offer kets, where sector-specific platforms services in other sectors, such as mobile may not be viable given their relatively money transfer, may provide a base on small user or customer base. In some which health services can be added. Recommendation 5 Create national ID systems to facilitate impact measurements Health records linked to uniquely iden- Further, the lack of measurable, longi- tifiable individuals are a key pillar of tudinal data is one of the biggest bar- successful eHealth strategies, because riers to eHealth investment because of their potential to improve continuity it prevents the ability to measure the of care, enable point-of-service devices, impact of the solutions and justify and feed nationwide health informa- the investment in these interventions. tion systems. The creation of unique After enabling national unique ID sys- identifiers that can form the basis of tems, governments should take a more individual, digitized health records is active role in conducting rigorous a strong first step. These unique IDs impact studies through robust moni- are also extremely useful for targeting toring and evaluation programmes, social protection systems. or through engaging universities and NGOs as research partners. Recommendation 6 Conduct a total cost of ownership analysis A common reason for the inability of given to training, support, maintenance eHealth interventions to scale or sus- and operating costs. Conducting a rig- tain themselves is the failure by plan- orous total cost of ownership study can ners to consider all of the financial costs prevent unforeseen costs from damag- associated with such programmes, and ing projects’ chances for success, and the comparative cost effectiveness with can also force planners and partners to non-ICT solutions. Technology costs, consider all of the elements they will especially hardware, often comprise an need to plan for and how each of them entire budget with inadequate attention will be funded. 23 Recommendations for donors Though policy makers play the cen- • Design a course of action to in- tral role in setting a course for na- clude ICT in planning discussions tional eHealth development, many with policy makers when consider- African countries remain heavily de- ing developmental investments. pendent on donor funds and expertise. The donor community plays a critical • Designate a role for the public and role in supporting and enabling sus- private sector, keeping in mind tainable and scalable eHealth solu- that government is a lead user and tions, and the following recommen- regulator of ICTs while the private dations are aimed to help donors and sector is primarily a lead provider. other health sector investors to: Recommendation 7 Incentivize policy makers to follow system rules Donors should encourage countries (i.e. interoperable, scalable, sustain- to adopt policies within a set of archi- able, multi-layered, and supported by tectures that enable developers and a private-public partnership) that must vendors to provide the best services be present before donors fund projects. and applications at the most afford- Countries that fulfil the conditions list- able prices. Donors could, for exam- ed on the checklists would then benefit ple, create or add to project checklists from a fast-track status on applications. the desired systems characteristics Recommendation 8 Establish cooperation within and between donor agencies Donors should use ICT to establish pre-empt disagreements and promote standards among themselves – regarding collaboration, thereby reducing overall nomenclature, metrics and databases. system costs, minimizing duplication They can use ICT to automatically and increasing the benefit of each of cross-reference one another’s research, their efforts. ICT systems that are built 24 only to support an individual donor’s Within their respective institutions, programmes, especially in disease- donors should archive and make avail- specific projects, are often cited as a able impact assessments for all projects, major reason for the fragmentation of and reward projects that provide useful the eHealth landscape. Donors can do assessments like impact analyses and their part to improve this situation by standardized return on investment cal- coordinating their technology funding culations. Such standardization should initiatives and seeking alignment with encourage policy makers, administra- each other on common standards, as tors and project designers to actively well as by adhering to the “rules” estab- and consciously integrate measure- lished by national governments. ment and evaluation into their eHealth strategies. Recommendation 9 Reward cross-sector and PPP efforts in eHealth systems development Donors should encourage and reward and ministries of health, technology countries that demonstrate a commit- and education with more revenue- ment to maximizing ICT for cross- driving ministries such as communica- sector and public-private partnership tion and finance. Donors should make (PPP) and collaborations. Such a po- cooperation within government, and sition among donors will encourage involvement of other relevant sectors, a meaningful dialogue, interaction and pre-requisite for financial or technical collaboration between such agencies assistance. 25 Further reading Foster, V. and Briceño-Garmendia, C. (2010) Africa’s Infrastructure: A Time for Transformation Agence Française de Développement and the World Bank http://siteresources.worldbank.org/INTAFRICA/Resources/aicd_overview_english_no-embargo.pdf Huet, J-M., Romdhane, M. and Tcheng, H. (2010) TIC et système de santé en Afrique Institut Francais des Relations Internationals http://www.ifri.org/?page=detail-contribution&id=6081 IFC (2007) The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives (2007) International Finance Corporation, World Bank Group http://www.unido.org/fileadmin/user_media/Services/PSD/BEP/IFC_HealthinAfrica_Final.pdf Prata, N. et al (2005) Private Sector, Human Resources and Health Franchising in Africa World Health Organization http://www.scielosp.org/scielo.php?pid=S0042-96862005000400011&script=sci_arttext UN (2010) Levels & Trends in Child Mortality Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation http://www.childinfo.org/files/Child_Mortality_Report_2010.pdf UN (2010) The Millennium Development Goals Report 2010 United Nations http://www.un.org/millenniumgoals/pdf/MDG%20Report%202010%20En%20r15%20-low%20 res%2020100615%20-.pdf Vital Wave Consulting (2011) mHealth in Ethiopia: Strategies for a New Framework http://www.vitalwaveconsulting.com/pdf/2011/mHealth%20Framework%20for%20Ethiopia%202011.pdf World Bank (2004) World Development Report: Making Services Work for Poor People http://www.worldbank.org/wdr www.eTransformAfrica.org Publications for eTransform Africa include the Summary Report, Main Report which includes an overview chapter and summary chapters of the full reports, and the full reports themselves covering the following sectors and cross-cutting themes: Sectors themes: Agriculture Climate Change Adaptation Education Financial Services Modernizing Government Health Cross-cutting themes: Regional Trade and Integration ICT Competitiveness For a more detailed presentation on the role of ICT in health in Africa, see the full eTransform Africa sector report: http://www.etransformafrica.org. 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