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Telehealth in the Developing = World

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Telehealth in the Developing World

Edited by

Richard Wootton

Scottish Centre for Telehealth, Aberdeen, = UK;
University of Queensland, Brisbane, Australia

Nivritti G Patil

University of Hong Kong, Hong Kong,=20 China

Richard E Scott

University of Calgary, Calgary,=20 Canada

Kendall Ho

University of British Columbia, = Vancouver,=20 Canada

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=A9 2009 Royal Society of Medicine Press Ltd

Co-published by
Royal Society of Medicine Press = Ltd
1=20 Wimpole Street, London W1G 0AE, UK
Tel: +44 (0)20 7290 2921
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Email: publishing@rsm.ac.uk
Website: http://www.rsmpress.co.uk/=

International Development Research Centre
PO Box = 8500,=20 Ottawa, ON K1G 3H9, Canada
Email: info@idrc.ca
Website: http://www.idrc.ca/

Apart from any fair dealing for the purposes of = research or=20 private study, criticism or review, as permitted under the UK Copyright, = Designs=20 and Patents Act, 1988, no part of this publication may be reproduced, = stored or=20 transmitted, in any form or by any means, without the prior permission = in=20 writing of the publishers or in the case of reprographic reproduction in = accordance with the terms of licences issued by the Copyright Licensing = Agency=20 in the UK, or in accordance with the terms of licences issued by the = appropriate=20 Reproduction Rights Organization outside the UK. Enquiries concerning=20 reproduction outside the terms stated here should be sent to the = publishers at=20 the UK address printed on this page.

The rights of Richard Wootton, Nivritti G Patil, = Richard E=20 Scott and Kendall Ho to be identified as Editors of this work have been = asserted=20 by them in accordance with the Copyright, Designs and Patents Act, = 1988.

This publication has been generously supported by a = grant=20 from the International Development Research Centre, Canada; with = additional=20 contributions from HiiTeC and the Faculty of Medicine, University of = Hong=20 Kong.

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A catalogue record for this book is available from the = British=20 Library

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Contributors	ix=
Foreword	xiii
Preface	xv=
SECTION 1: = BACKGROUND
1. Introduction	3
Richard Wootton, Kendall Ho, = Nivritti G Patil=20 and Richard E Scott
SECTION 2: = POLICY
2. Bridging the digital = divide:=20 Linking health and ICT policy	9
Joan Dzenowagis
3. Telemedicine in = developing=20 countries: Perspectives from the Philippines	27
Alvin B Marcelo
4. Information = technology for=20 primary health care in Brazil	34
Elaine Tomasi, Luiz A Facchini, = Elaine Thum=E9,=20 Maria FS Maia and Alessander Osorio
5. Community-based = health workers=20 in developing countries and the role of m-health	43
Adesina Iluyemi
6. Global e-health = policy: From=20 concept to strategy	55
Richard E Scott
7. Experiences and = lessons learnt=20 from telemedicine projects supported by the IDRC	68
Laurent Elder and Michael=20 Clarke
8. Strategies to promote = e-health=20 and telemedicine activities in developing countries	79
Sisira Edirippulige, Rohana B = Marasinghe,=20 Vajira H W Dissanayake, Palitha Abeykoon and Richard=20 Wootton
SECTION 3: = EDUCATIONAL
9. Telemedicine in = low-resource=20 settings: Experience with a telemedicine service for HIV/AIDS = care	91
Maria Zolfo, Verena Renggli, Olivier = Koole and=20 Lut Lynen
10. Medical Missions for = Children:=20 A global telemedicine and teaching network	101
Philip O Ozuah and Marina=20 Reznik
11. Telementoring in = India:=20 Experience with endocrine surgery	109
Saroj K Mishra, Puthen V Pradeep = and Anjali=20 Mishra
SECTION 4: = CLINICAL
12. Teledermatology in = developing=20 countries	121
Steven Kaddu, Carrie Kovarik, = Gerald Gabler=20 and H Peter Soyer
13. Cross-cultural = telemedicine=20 via email: Experience in Cambodia and the USA	135
Paul Heinzelmann, Rithy Chau, = Daniel Liu and=20 Joseph Kvedar
14. Telepathology and = telecytology=20 in developing countries	149
Sangeeta Desai
15. Internet-based=20 store-and-forward telemedicine for subspecialty consultations in = the=20 Pacific region	156
C Becket Mahnke, Charles W Callahan = and=20 Donald A Person
16. Telehealth support = for a=20 global network of Italian hospitals	170
Gianfranco Costanzo and Paola=20 Monari
17. Telemedicine in = Nepal	182
Mohan R Pradhan
18. Telemedical support = for=20 surgeons in Ecuador	193
Stephen Cone, Edgar J Rodas and = Ronald C=20 Merrell
19. A low-cost = international=20 e-referral network	203
Richard Wootton, Pat Swinfen, Roger = Swinfen=20 and Peter Brooks
20. Telehealth in China: = Opportunities and challenges	212
Jie Chen and Zhiyuan = Xia
21. Telemedicine in = South=20 Africa	222
Maurice Mars
22. Telemedicine in = sub-Saharan=20 Africa	232
Maurice Mars
23. Telehealth for = mountainous and=20 remote areas of northern Pakistan	242
Hameed A Khan and Irfan = Hayee
24. Teleneurology: Past, = present=20 and future	252
Usha K Misra and Jayantee=20 Kalita
25. Telepaediatric = support for a=20 field hospital in Chechnya	262
Boris A Kobrinskiy and Vladimir I=20 Petlakh
26. Web-based paediatric = oncology=20 information and registries: An international perspective	273
Andr=E9 Nebel de = Mello
27. E-health in = international=20 networks: New opportunities for collaboration	287
Shariq Khoja and Azra = Naseem
SECTION 5: THE = FUTURE
28. The future use of = telehealth=20 in the developing world	299
Richard Wootton
Index	309

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Contributors

Palitha Abeykoon Ministry of = Health, Colombo,=20 Sri Lanka

Peter Brooks Faculty of Health = Sciences,=20 University of Queensland, Brisbane, Australia

Charles W Callahan De Witt Army = Community=20 Hospital, Ft Belvoir, Virginia, USA

Rithy Chau Sihanouk Hospital Center = for HOPE,=20 Phnom Penh, Cambodia

Jie Chen Key Laboratory of Health = Technology=20 Assessment, Ministry of Health; School of Public Health, Fudan = University,=20 Shanghai, China

Michael Clarke International = Development=20 Research Centre, Ottawa, Canada

Stephen Cone Virginia Commonwealth = University=20 Medical Center, Richmond, Virginia, USA

Gianfranco Costanzo Ministry of = Labour,=20 Health and Social Policies, Alliance of the Italian Hospitals Worldwide = =96=20 Secretariat for Technical Assistance, Rome, Italy

Sangeeta Desai Department of = Pathology, Tata=20 Memorial Hospital, Mumbai, India

Vajira H W Dissanayake Human = Genetics Unit,=20 Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Joan Dzenowagis World Health = Organization,=20 Geneva, Switzerland

Sisira Edirippulige Centre for = Online Health,=20 University of Queensland, Brisbane, Australia

Laurent Elder International = Development=20 Research Centre, Ottawa, Canada

Luiz A Facchini Department of = Social=20 Medicine, University Federal of Pelotas, Pelotas, Brazil

Gerald Gabler Department of IT and=20 Telecommunications, Graz University Clinics and General Hospital, Graz,=20 Austria

Irfan Hayee COMSATS Headquarters, = Islamabad,=20 Pakistan

Paul Heinzelmann Center for = Connected Health,=20 Partners HealthCare; Department of Medicine, Massachusetts General = Hospital,=20 Harvard Medical School, Boston, Massachusetts, USA

Kendall Ho Faculty of Medicine, = University of=20 British Columbia, Vancouver, Canada

Adesina Iluyemi Centre for = Healthcare=20 Modelling and Informatics, School of Computing, University of = Portsmouth, UK

Steven Kaddu Department of = Dermatology,=20 Medical University of Graz, Graz, Austria

Jayantee Kalita Department of = Neurology,=20 Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, = India

Hameed A Khan Pakistan Atomic = Energy=20 Commission, Islamabad, Pakistan

Shariq Khoja Faculty of Health = Sciences, Aga=20 Khan University, Karachi, Pakistan

Boris A Kobrinskiy Moscow Research = Institute=20 of Paediatrics and Children=92s Surgery, Moscow, Russia

Olivier Koole Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

Carrie Kovarik Department of = Dermatology,=20 Dermatopathology, and Infectious Diseases, University of Pennsylvania,=20 Philadelphia, USA

Joseph Kvedar Center for Connected = Health,=20 Partners HealthCare; Department of Dermatology, Massachusetts General = Hospital,=20 Harvard Medical School, Boston, Massachusetts, USA

Daniel Liu Sihanouk Hospital Center = for HOPE,=20 Phnom Penh, Cambodia

Lut Lynen Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

C Becket Mahnke Tripler Army = Medical Center,=20 Honolulu, USA

Maria F S Maia University Federal = of Pelotas,=20 Pelotas, Brazil

Rohana B Marasinghe Centre for = Online Health,=20 University of Queensland, Brisbane, Australia

Alvin B Marcelo National Telehealth = Center,=20 University of the Philippines, Philippines

Maurice Mars Nelson R Mandela = School of=20 Medicine, University of KwaZulu-Natal, South Africa

Ronald C Merrell Virginia = Commonwealth=20 University Medical Center, Richmond, Virginia, USA

Anjali Mishra Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Saroj K Mishra Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Usha K Misra Department of = Neurology, Sanjay=20 Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Paola Monari Alliance of the = Italian=20 Hospitals Worldwide =96 Secretariat for Technical Assistance, Rome, = Italy

Azra Naseem Institute of = Educational=20 Development, Aga Khan University, Karachi, Pakistan

Andre Nebel de Mello Laboratorio de = Sistemas=20 Integraveis da Escola Polictecnica da Universidade de S=E3o Paulo, S=E3o = Paulo,=20 Brazil

Alessander Osorio University = Federal of=20 Pelotas, Pelotas, Brazil

Philip O Ozuah Children=92s = Hospital at=20 Montefiore, Albert Einstein College of Medicine, New York, USA

Nivritti G Patil University of Hong = Kong,=20 Hong Kong, China

Donald A Person Tripler Army = Medical Center,=20 Honolulu, USA

Vladimir I Petlakh Moscow Research = Institute=20 of Paediatrics and Children=92s Surgery, Moscow, Russia

Puthen V Pradeep Sanjay Gandhi = Postgraduate=20 Institute of Medical Sciences, Lucknow, India

Mohan R Pradhan Health Net, = Kathmandhu,=20 Nepal

Verena Renggli Institute of = Tropical=20 Medicine, Department of Clinical Sciences, Antwerp, Belgium

Marina Reznik Children=92s Hospital = at=20 Montefiore, Albert Einstein College of Medicine, New York, USA

Edgar J Rodas University of Azuay, = Cuenca,=20 Ecuador

Richard E Scott Health Innovation = and=20 Information Technology Centre (HiiTeC), University of Calgary, Calgary,=20 Canada

H Peter Soyer Dermatology Group, = School of=20 Medicine, University of Queensland, Brisbane, Australia

Pat Swinfen Swinfen Charitable = Trust,=20 Canterbury, UK

Roger Swinfen Swinfen Charitable = Trust,=20 Canterbury, UK

Elaine Thum=E9 Department of = Nursing,=20 University Federal of Pelotas, Pelotas, Brazil

Elaine Tomasi Department of = Psychology,=20 University Catholic of Pelotas, Pelotas, Brazil

Richard Wootton Scottish Centre for = Telehealth, Aberdeen, UK; University of Queensland, Brisbane, = Australia

Zhiyuan Xia Telemedicine Centre, = Fudan=20 University, Shanghai, China

Maria Zolfo Institute of Tropical = Medicine,=20 Department of Clinical Sciences, Antwerp, Belgium

Foreword

Telehealth in the Developing World is a = very=20 wide-ranging book, rich in practical experience, which will be of = interest both=20 to those who want to learn about the developing world and to those who = want to=20 learn from developing countries. It is full of real-life stories. = Telemedicine,=20 rightly in my view, is seen as central to the improvement of health and = life in=20 developing countries. Much has been said and written about telemedicine = and its=20 potential to transform life, but these are still early days. A great = deal of=20 what has been written and said has been theoretical. This book reflects = the=20 reality.

All the projects described here have been driven by = people of=20 vision and passion. All have had to confront the problems of the real = world,=20 whether these have been the realities of desperate poverty or the, = equally real,=20 obstacles of clinical, technical and governmental politics. All the = pioneers=20 have been on journeys of discovery, working out how to be effective in = the=20 particular environment where they are operating. Who can fail to be = impressed by=20 the Swinfen Charitable Trust and its journey? It has pioneered the use = of the=20 simplest of modern electronic technology to ensure that people working = in=20 isolation in poor countries can benefit from the opinions of specialists = in the=20 richest countries.

Other impressive pioneering work in particular = specialities =96=20 such as teledermatology, telepaediatrics, telepathology, telepsychiatry = and=20 e-mental health =96 is described here. There are also descriptions of = progress in=20 developing countries, such as China, Pakistan, Chechnya and Ecuador, as = well as=20 accounts of linking with Italian expatriates and cross-cultural = experiences=20 between the USA and Cambodia.

Importantly, these accounts show how telemedicine = enables=20 professionals to be put in touch with other professionals. Individual = clinicians=20 in remote areas are able to tap into advice from their peers and, very=20 motivationally, to feel part of their profession and of an international = group=20 of colleagues. This by-product of telemedicine must not be = underestimated. It=20 has sustained human beings when other resources have failed.

Underpinning all this are accounts of public and = technical=20 policy that attempt to answer the question of how the enthusiasm of the = pioneers=20 can be turned into sustainable mainstream activity. This is, of course, = the=20 vital question.

Health care, as we know, is primarily about = people-to-people=20 interactions. It is about understanding, diagnosis, physical contact,=20 communication and, ultimately, providing care. All of this is = facilitated by the=20 technical processes of imaging, pathological testing, information = gathering,=20 research and so forth. The task for every health care system is how to = maximize=20 the personal contact at the same time as maximizing the=20 technical input, while all the time operating within a sustainable = financial=20 framework.

People working in developing countries have had to = think about=20 this task with even more urgency than those of us working in richer = countries.=20 They have had to think about how to obtain an expert opinion in remote = places,=20 how to support local clinicians who may not have all the skills they = need, how=20 to make sure technical information is interpreted wisely in very = difficult=20 circumstances and how best to use very scarce resources. Telemedicine = offers=20 help in meeting these conflicting needs by improving access to data and = to=20 individuals, while driving down the costs of doing so.

We in the developed world have large and = industrialized health=20 systems that grow costlier by the day as we absorb new technologies. At = some=20 point, as costs and demand both rise, we too will need to learn some of = the=20 lessons that our colleagues are learning in Africa, South America and = Asia. The=20 pioneers in this book are learning lessons for developing countries. = They are=20 learning lessons for us all.

LORD CRISP
Honorary Professor at the London School = of=20 Hygiene and Tropical Medicine

Preface

This is the ninth book in the Royal Society of = Medicine=92s=20 series of multi-author books on telemedicine topics. The series aims to = provide=20 examples of best practice. This book=92s predecessors are:

The = Legal and=20 Ethical Aspects of Telemedicine, BA Stanberry, 1998

= Introduction to=20 Telemedicine, R Wootton and J Craig (eds), 1999

=20 Teledermatology, R Wootton and AMM Oakley (eds), 2002

= Telepsychiatry=20 and e-Mental Health, R Wootton, P Yellowlees and P McLaren (eds), = 2003

= Telepediatrics:=20 Telemedicine and Child Health, R Wootton and J Batch (eds), = 2004

=20 Teleneurology, R Wootton and V Patterson (eds), 2005

= Introduction to=20 Telemedicine, 2nd edition, R Wootton, J Craig and V Patterson = (eds),=20 2006

Home = Telehealth:=20 Connecting Care Within the Community, R Wootton, SL Dimmick and JC = Kvedar=20 (eds), 2006

Much has been written about the potential use of = telemedicine=20 in developing countries, but equally much of it has been criticized as = little=20 more than wishful thinking. While it is sometimes said that there are = relatively=20 few cost-effective and sustainable telemedicine projects in the = industrialized=20 world, there are even fewer in developing countries. The present volume=20 therefore aims to summarize the experience of starting and sustaining = telehealth=20 projects in the developing world. It represents a description of how=20 telemedicine in the broadest sense can be applied to improve the = delivery of=20 health care in developing countries.

The book=92s contributors have substantial practical = experience=20 across a wide range of application areas, and most have published = previous=20 reports of their work in the peer-reviewed literature.

It is a pleasure to acknowledge the support of = Canada=92s=20 International Research and Development Centre, the Li Ka Shing Faculty = of=20 Medicine at the University of Hong Kong, the Health Innovation and = Information=20 Technology Centre (HiiTeC) of the University of Calgary, and the U21 = Health=20 Sciences Group in the production of the book. We have divided the = material into=20 sections:

background = and=20 introductory material

a section = on policy=20 matters

a section = describing=20 educational applications

a section = about=20 clinical applications

a view of = the=20 future.

We hope that within the broad spectrum of ideas = expressed in=20 this book everyone will find something of relevance. We also hope that = you enjoy=20 reading it.

RICHARD WOOTTON
Edinburgh, UK

KENDALL HO
Vancouver, Canada

NIVRITTI G PATIL
Hong Kong, China

RICHARD E SCOTT
Calgary, Canada

SECTION 1
BACKGROUND

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1 Introduction

Richard Wootton, Kendall Ho, Nivritti G Patil = and=20 Richard E Scott

What is telemedicine?

There is no generally accepted definition of = telemedicine. The=20 literal meaning is =91health[care] at a distance=92. Thus, telemedicine = may=20 represent health care practised in real time, using a video link for = example, or=20 asynchronously, perhaps by email. The type of health care interaction is = perfectly general, and may encompass diagnosis and management, education = =96 of=20 staff, patients and the general population =96 and administrative = meetings.

The history of telemedicine has been bedevilled by = loose=20 terminology, which, some observers feel, has not assisted its = cause.1 What = began=20 originally as =91telemedicine=92 has become successively = =91telehealth=92, =91online=20 health=92, =91e-health=92, =91connected health=92, etc. In this book, = different=20 contributors use slightly different terms to describe their telemedicine = experience, depending on their local environment. While the editors have = tried=20 to reduce the number of terms used, we have deliberately not enforced a = uniform=20 terminology throughout, in recognition of these local differences.

Scope of the problem

Telemedicine is one aspect of the use of information = and=20 communication technology (ICT) in health care. It is widely believed = that ICT=20 generally has the potential to improve clinical care and public health. = In=20 addition to facilitating medical education, administration and research, = appropriate use of ICT may:

improve = access to=20 health care;

enhance = the quality=20 of service delivery;

improve = the=20 effectiveness of public health and primary care interventions;

improve = the global=20 shortage of health professionals through collaboration and training.

However, many questions remain about the potential = value to=20 people in resource-constrained settings such as the developing = world.

There are major problems of inequity of access to = health care in=20 developing countries, to which telemedicine offers a potential solution. = It may=20 be valuable in other ways as well.

Crisp report

In 2007, Lord Crisp reported about how UK experience = and=20 expertise in health could best be used to help improve health in = developing=20 countries.2 He = concluded=20 that sufficient progress towards the United Nations=92 Millennium = Development=20 Goals (e.g. in reducing child and maternal deaths, and tackling = HIV/AIDS,=20 tuberculosis and malaria) would not occur unless:

developing = countries=20 are able to take the lead and own the solutions =96 and are supported by = international, national and local partnerships based on mutual = respect;

the UK and = other=20 industrialized countries grasp the opportunity =96 and see themselves as = having a=20 responsibility as global employers =96 to support a massive scaling-up = of=20 training, education and employment of health workers in developing=20 countries;

there is = much more=20 rigorous research and evaluation of what works, systematic spreading of = good=20 practice, greater use of new information, communication and biomedical=20 technologies, closer links with economic development, and an = accompanying=20 reduction in wasted effort.

Clearly, telemedicine could play a major part in = facilitating=20 all of these activities. Furthermore, one can imagine the consequences = if every=20 hospital in the richer countries were to be linked up on a formal basis = with a=20 small group of hospitals or health centres in developing countries. = Through=20 mutual learning and collaboration in health service provision, such = health=20 partnerships could ultimately change health-care delivery at the = national level;=20 they might also change how the industrialized nations perceive the = world.=20 Telemedicine and ICT would be essential to maximizing the potential of = these=20 health partnerships.

Aim of the book

Any discussion of telemedicine in the developing = world raises=20 difficult questions about resource use, sustainability and global equity = in=20 access to health care. Despite the large number of published articles on = the=20 concept of telemedicine in the developing world, there are = remarkably=20 few examples of successful implementation.3 In = this book,=20 we have attempted to assemble a representative cross-section of the very = wide=20 range of work that has been carried out to date. Thus, the book offers a = state-of-the-art review of telemedicine in the developing world, and = should also=20 provide the basis for a high-level operations manual. It could be = considered=20 unethical, after all, not to learn from the experience of others and to = squander=20 scarce resources on an idea that may have already been proved to be=20 unfeasible.

The major sections of the book cover policy, clinical = and=20 educational matters. We hope that you enjoy reading it.

References

1=20 Wootton R. Telemedicine and isolated communities: a UK perspective. = J=20 Telemed Telecare 1999; 5(Suppl 2): 27=9634.

2=20 Crisp N. Global Health Partnerships. The UK Contribution to Health = in=20 Developing Countries. London: COI, 2007. Available at:=20 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolic= y-AndGuidance/DH_065374.

3=20 Wootton R. Telemedicine support for the developing world. J Telemed=20 Telecare 2008; 14: 109=9614.

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SECTION 2
POLICY

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2 Bridging the digital divide: Linking health and = ICT=20 policy

Joan Dzenowagis

Introduction

The past decade has seen a remarkable growth in the = diffusion=20 of information and communication technology (ICT) across the world. This = growth=20 has been fuelled by technological advances, economic investment, and = social and=20 cultural changes that have facilitated the integration of ICT into = everyday=20 life. The general public =96 consumers =96 as well as a range of new = stakeholders=20 have had a significant impact on shaping this growth, for example by = demanding=20 better products, services and value for money. As these technologies = enter the=20 mainstream of business and cultural life, there is also a greater = awareness of=20 their potential as economic and social tools and, with it, new social = and=20 political pressure to re-frame ICT as a public good to be made = accessible and=20 available to all. This shift has had important ramifications in = countries and at=20 the international level as well.

Despite this encouraging progress, however, the uptake = of ICT=20 globally continues at an uneven pace, and the =91digital divide=92 = remains a=20 significant obstacle to achieving global development goals. The digital = divide=20 is understood broadly to be the gap between those with access to ICT and = its=20 benefits and those without. It is specifically acknowledged in the = United=20 Nations Millennium Development Goals (MDGs). Goal 8, Target 18 of the = MDGs=20 proposes =91a global partnership for development to make available the = benefits of=20 new technologies, especially information and communication = technologies=92.1

Recent events such as the G8 Summits and the World = Summit on the=20 Information Society2 have = continued=20 to promote this target and to highlight the striking gaps in access to = ICT=20 worldwide. In some countries, both urban and rural regions remain = isolated from=20 the knowledge society: infrastructure is non-existent, costs for basic = services=20 are beyond average income levels and well-intentioned ICT pilot projects = end=20 without ever scaling-up. While this can be disastrous for national = economies=20 competing in a global environment, it is also a tragedy for the health = sector,=20 where ICT is essential to improve health and help alleviate = inequalities.

ICT in the health sector

In the health sector, ICT is a cornerstone of = efficient and=20 effective services. In many countries, use of ICT within the sector = continues to=20 grow, and the Internet in particular is driving significant change. For = example,=20 in middle- and high-income countries, the Internet is dramatically = changing the=20 way in which consumers interact with health services, including access = to health=20 information and the ability to purchase pharmaceuticals and other health = products. The Internet also plays a key role in expanding the reach of = health=20 services to remote areas. The spread of broadband networks and the = development=20 of new e-health applications, defined as the use of ICT for health, have = a=20 mutually stimulating effect on further developments. However, it is = clear that,=20 despite the numerous creative and sometimes quite costly efforts to = improve the=20 situation, access to these developments is not universal, and many = countries do=20 not benefit as they might from advances in ICT in health.

For policy makers committed to improving national = health=20 systems, working with ICT policy makers and participating in the = national=20 policy-making process is essential to ensure that national ICT policy, = when=20 implemented, will meet the interests of the health sector in the years = to=20 come.

Measuring the digital divide

It has only been within the past few years that = meaningful=20 measures of the digital divide have been developed. The potential choice = of=20 indicators is enormous and the continuing evolution of technology = shortens the=20 useful lifespan of established indicators, creating the need for their = regular=20 revision. However, whether measured by ICT diffusion, technology = investment or=20 other related measures, the digital divide is manifest within and = between=20 countries in a variety of ways.

The digital divide is evident in low-income countries, = where=20 technology is unaffordable for private enterprise as well as for = individuals,=20 and where government policies and regulations do not encourage or = support ICT=20 business development. It is evident in the contrast between urban and = rural=20 areas, where investment in basic ICT infrastructure and services is = chronically=20 inadequate. It is also evident in communities and households, where = literacy=20 rates, educational levels and incomes are low and where content imported = from=20 abroad does not suit local needs or transmit in local languages. Most of = these=20 aspects are captured by the ICT Diffusion Index,3 which = takes=20 into account the complex dimensions of access, connectivity and policy = in=20 countries. The index results in a composite score between 0 and 1, = giving a=20 picture of ICT status in general but not addressing ICT diffusion by = sector. The=20 link between ICT, health and development is clear in Figure 2.1, = showing=20 country ICT diffusion and mortality strata, by WHO region.4,5

Following the World Summit on the Information Society = in 2003=20 and 2005, many countries undertook the development of national = strategies that=20 aimed to increase the use of ICT. Such strategies sought to increase = investment=20 and stimulate innovation, particularly in small and medium enterprises = in the=20 private sector, and to improve

3DImage=20

Figure 2.1 ICT diffusion and = mortality.=20 (Stratum 1 =3D very high adult and very high child mortality; stratum 5 = =3D low=20 adult and low child mortality.)

efficiency and effectiveness in the public sector = (e.g. in=20 government and education). For both the public and private sectors, the = use of=20 ICT in health, or e-health, is considered to represent a key instrument = for=20 health care delivery and public health action,6 and a = number of=20 governments have supported specific investments and policy instruments = towards=20 this end.

In high- and low-income countries, e-health has = already=20 demonstrated its value, particularly in containing cross-border threats = to=20 health and safety. However despite the documented value of ICT in terms = of=20 improving quality, cost and access to health care, the picture globally = remains=20 mixed. In particular, the ability to plan and implement e-health on a = large=20 scale, while adapting it to local health problems, presents a huge = challenge for=20 countries and institutions.

Despite the difficulties, there have been major ICT = investments,=20 particularly in countries such as those in Eastern Europe. These = economies are=20 growing rapidly, and large-scale infrastructure investments supported by = the=20 European Union include ICT for health institutions and universities. In=20 higher-income countries, there is spending in the areas of information = systems,=20 electronic health records, e-prescribing systems, diagnostic tools and = medical=20 imaging. In developing countries, ICT pilot projects are being funded by = international donors, leading to uncoordinated deployment of ICT in = health=20 service delivery and incompatible systems at many levels. In addition,=20 investments are being made in applications that support =91vertical=92 = health=20 programmes such as disease surveillance, management = of drug=20 supply, and planning and monitoring human resources for health.

Driving forces for ICT in health

Challenges in global public = health

Despite significant progress in public health over = the past 50=20 years, the fundamental conditions for health have not been achieved in = many=20 countries. Most of the burden of premature death and illness among the = poor is=20 due to problems for which solutions are known and prevention is = possible, yet=20 the health of populations in developing countries continues to be at = risk.=20 Today, the gap in health between the wealthy and the poor, both within = and=20 between countries, continues to grow.

The health divide is evident especially in low-income = countries,=20 which face a high burden of endemic and epidemic-prone infectious = diseases,=20 unacceptably high levels of child and maternal mortality, a continuing = HIV/AIDS=20 pandemic and the rapid spread of chronic conditions accelerated by = poverty. In=20 many countries, there is a deepening crisis in access to basic health = services,=20 linked to a shortage of essential health workers.7 In = the face of=20 these and numerous other challenges, governments are attempting to build = and=20 sustain their health systems.

Over the last decade, the need to develop and organize = new ways=20 of providing health services has been accompanied by major advances in = ICT,=20 enabling better support for health services and systems, and improving = global=20 awareness of health issues. These technologies hold great promise for = the health=20 sector in both low- and high-income countries, and some countries are = realizing=20 the benefits today. This is true not only for the delivery of health = services,=20 but also for health-related markets more generally. As the use of ICT = grows, it=20 is vital that the health sector participates in key international forums = and=20 helps to shape national policy to ensure that ICT improves outcomes for = health,=20 particularly for the most vulnerable populations.

Forces for change

In all countries, including developing countries, = forces from=20 health care and the ICT industry are spurring the growth of e-health. = These=20 forces include industry developments in wireless and satellite systems, = the=20 spread of broadband communications, better access to applications and = services,=20 and increasing digital processing power and storage capacity. This = growth has=20 led to significant regulatory change, advances in consumer protection, = greater=20 patient mobility, and new opportunities for trade and cross-border = services in=20 health.8 In = the health=20 sector, driving forces for adoption of ICT include such factors as = government=20 pressures to control costs, chronic and ever-increasing health work = force=20 shortages, greater expectations by consumers for higher quality and = safer care,=20 and changing models of health care delivery.

From the micro-level to the macro-level, from basic = human=20 genetics research to the provision of humanitarian aid and disaster = relief to=20 populations at risk, ICT supports the health sector in addressing a vast = range=20 of immediate and long-term challenges to human life and health, through = the=20 functions outlined in Table = 2.1.

Table 2.1 Examples of the use = of ICT in=20 health systems and services
Broad area	Examples
Access to information and knowledge	1. Improved access to health information, = research,=20 literature and training materials, such as access to biomedical = and social=20 sciences research. This supports the health research enterprise = and=20 enables comprehensive, evidence-based management of acute and = chronic=20 conditions
	2. Improved access to resources on prevention, = awareness=20 and education, for the general public as well as for health = professionals,=20 researchers and policy makers
Networking and collaboration	1. Collaboration for the management and = coordination of=20 care across different health providers, community health services = and=20 health institutions
	2. Better exchange of knowledge among policy = makers,=20 practitioners and advocacy groups
	3. Rapid and coordinated response to disasters = and=20 disease events
Information for policy and action: measuring = progress,=20 tracking quality and trend analysis	1. ICT for collecting, organizing and = disseminating=20 public health evidence and information for advocacy, practice and=20 policy
	2. Improved ability to describe, model, analyze = and=20 monitor trends on health status, income, employment and service = coverage,=20 and disaggregate by gender
	3. Support for research on policy = effectiveness
Health education and training	1. Direct support to education and training for = health=20 professionals and workers, including both pre-service education = and=20 in-service training and resources
	2. Improved efficiency and effectiveness of = education=20 delivery through strategic application of ICT and ICT-enabled = skill=20 development
	3. Improved availability of quality educational = resources=20 through ICT
	4. Outreach to special populations (girls and = women)=20 using appropriate technologies
	5. Enhanced delivery of basic and in-service=20 education
Public accountability through greater flow of=20 information	1. Greater transparency, accountability and = accessibility=20 in delivery of public services
	2. Improved enforcement of regulations and = performance=20 monitoring of decentralized services
Delivery of health services	1. Prevention of disease, health education and = promotion,=20 and support for diagnosis and treatment
	2. Establishment of health registries and = health=20 information systems
	3. Extension of care to rural and remote areas = through=20 telemedicine applications; increased access of rural health = workers to=20 specialist support and consultation

A number of these uses of ICT promise particular = benefits for=20 developing countries. For example, decreasing the isolation of the = health=20 community is seen as a major benefit, and is thus a driver for adoption. = ICT is=20 increasingly well integrated in educational settings in middle- and = high-income=20 countries, where communication, collaboration and access to information = are at=20 the core of research and teaching. Universities in the developing world = need to=20 connect on an equal footing with their counterparts. This access will = play an=20 important role in advancing locally relevant research, and will improve = capacity=20 by enabling participation in the peer-review process required for = publishing and=20 participation in research conferences.

Improved access to care is an important benefit of = ICT,=20 particularly for countries tackling the challenge of providing health = care to=20 people over a broad geographical area. One of the main drivers behind = public=20 investment in e-health systems is the expectation that ICT will improve = access=20 to services and reduce the inequities experienced by people in remote = locations.=20 This is a serious matter in countries that have chronic shortages of = physicians,=20 nurses and health technicians. The problem of shortages is often coupled = with=20 public concern over access and demographic shifts with concomitant major = health=20 resource implications, such as ageing populations and rapid population = growth in=20 native or aboriginal communities.9 In = contexts=20 such as these, the goal of access to health care has driven the adoption = of ICT=20 for remote diagnosis, monitoring and consultation.

Quality of care is another important driver for ICT = adoption.=20 Health service providers are not only attempting to deliver more = effective care,=20 they are also attempting to deliver care that is safe. Both goals = require the=20 use of ICT to measure, monitor and report on quality improvement = initiatives, as=20 well as the use of information systems =96 such as pharmaceutical = ordering systems=20 =96 that are proven to reduce errors.10 = Developments=20 such as e-prescription and computer-assisted imaging are part of this. = With=20 respect to technology-assisted care, it is critical to ensure that the = care and=20 information provided through e-health meet appropriate standards, = relating to=20 the quality of information transmitted as well as to the overall = reliability of=20 the system and the satisfaction of users, both professionals and = patients.

To date, e-health has mainly been used to improve = productivity=20 in delivery systems focused on patients and hospitals. In the future, it = can be=20 expected that ICT will be used to facilitate personalized and = home-centred care.=20 To this end, there has been significant investment in research and = development,=20 such as in the European Union (EU) Framework Programmes, which have = invested=20 over 500 million euros in establishing a European health area, e-health=20 conferences and an e-health action plan.11

The concept of citizen-centred care has become the = basis of=20 programmes designed to empower consumers in part by improving the health = information environment. Many observers expect that the Internet and the = web=20 will become the place to obtain health advice for citizens. In 2007, the = worldwide Internet population was estimated at 15.8 users per 100 = inhabitants,=20 up from 5.3 users per 100 in 1999.4 = Health is=20 consistently among the most sought-after types of Internet = information.12 = Some=20 governments, worried that the volume and quality of health information = on the=20 Internet might pose a risk to citizens, have responded by creating or = sponsoring=20 health information portals. Others have provided guidelines for website = quality=20 and promoted consumer education as a protection against the growing = problem of=20 Internet fraud and spam.

Economy and efficiency of care is another important = driver for=20 the adoption of ICT in health. Key areas aimed at controlling costs over = the=20 long term include hospital information systems, regional networks, = secure=20 reimbursement and procurement systems, and patient =91smart cards=92 = carrying=20 personal medical data. The electronic health record is central to the = ability to=20 improve quality, access and economy of care. It is also fundamental to = realizing=20 the concept of an expanded, digitized health care network that enables = more=20 effective public health services.

Just as ICT is at the core of much of the improvement = in=20 national health systems, global health security is = also=20 critically dependent on ICT. Reliable and secure ICT systems enable = tracking of=20 diseases and monitoring of populations at risk, and provide the basis = for global=20 defence against bioterrorism as well as early response to natural and = man-made=20 disasters. For example, the best way to prevent international spread of = diseases=20 is by detecting public health risks early and mounting an effective = response=20 while the problem is still localized. Rapid reporting, enabled and = validated=20 through global electronic communication, was a critical factor in the=20 containment of the SARS epidemic in 2003 and is a key aspect of = preparedness for=20 pandemics such as that anticipated with avian influenza. Fortunately, = steady=20 improvements in satellite technology, and particularly its more = widespread use,=20 have enabled a faster, more coordinated response globally and nationally = to=20 disease events and natural disasters.13

An overview of ICT policy

It is important for health policy makers to have an = overview=20 of the forces and policies that shape the availability and cost of ICT, = and to=20 understand potential points of influence. This will ensure that the = health=20 sector benefits from ICT to the greatest extent possible. Globally, the = ICT=20 policy picture is complex and changing, and is not easily governed by=20 traditional forms of national and international public authority. Beyond = this,=20 the Internet in particular has given rise to new patterns of = international=20 cooperation. Whereas the technical management of the Internet is = dominated by=20 companies working in industry forums to devise private systems of rules, = in=20 parallel governments and firms are collaborating to devise shared rules = on=20 communications behaviour and global electronic commerce conducted over = that=20 infrastructure.14 = This is not a=20 trivial matter for the health sector, as decisions made in this unwieldy = international system will have a direct effect on the future development = of=20 e-health, such as patient mobility and the viability of cross-border = services in=20 health.

Interested parties

In addition to governments, other major stakeholders = in the=20 ICT policy-making process include a wide range of organizations and = firms, such=20 as international organizations (e.g. the United Nations, the = International=20 Telecommunication Union and the World Trade Organization), consumer = rights=20 organizations (e.g. Consumers International), regional Internet = registries,=20 private businesses (e.g. ICT systems and equipment vendors, = telecommunications=20 operators, Internet service providers, and financial and certification=20 companies), business forums (e.g. the International Chamber of Commerce) = and=20 civil society organizations (e.g. Privacy International and the = Association for=20 Progressive Communications). A wide variety of civil society = organizations are=20 increasingly engaged in ICT forums in order to have their perspective = reflected=20 in ICT debates.

Pivotal role of = governments

While the above groups are active in seeking = influence at the=20 international level, government policy at the national level can have a = dramatic=20 effect on the diffusion of ICT.15 It = is=20 governments that create the policy environment that will foster = technology use=20 and encourage national and international investment in ICT = infrastructure,=20 development and a skilled workforce. Government action is also important = in=20 extending the benefits of technology to all social groups, as = governments have=20 the power and mandate to balance the needs of their citizens for = long-term=20 economic growth and social prosperity. Ultimately, how and what users = have=20 access to depend on specific legal, economic, political and social = conditions.=20 Not least, national systems of innovation strongly influence the = diffusion=20 process in a country.16

Linking health goals to ICT = policy

ICT represents not a single innovation but rather a = cluster of=20 related technologies that must be present together to support adoption = by users,=20 such as servers, communication links, software and user devices. In the = simple=20 model shown in Figure=20 2.2 there are three levels. At the bottom, is the connectivity level = or=20 underlying telecommunications and network infrastructure level, without = which=20 there can be no ICT. In the middle, a services level consists of = organizations=20 providing ICT applications and services, reflecting the extent to which = ICT=20 services are available in a country. At the top, is the individual and=20 organizational user level, where ICT adoption is typically measured by = the=20 overall number of users in a country.17

Policy implemented at each level affects meaningful = access to=20 ICT in a country and therefore in the health sector. Policies on the=20 infrastructure level provide the basis for expanding physical = infrastructure=20 such as satellite, wireless and broadband by shaping market conditions = and=20 competition. Providing access to technology is critical, but more than = physical=20 access is necessary. Networks and services are insufficient if ICT

3DImage=20

Figure 2.2 A simple framework for=20 understanding ICT policy. (Adapted from Wolcott et al.17)

is not used because it is not affordable, people = cannot=20 understand how to use it or the local economy cannot sustain its use. = Policies=20 at the services level therefore shape the legal and regulatory framework = that=20 creates conditions for a viable, secure online environment, promotes = diffusion=20 and uptake of services, and supports minimum levels of consumer = protection. At=20 the user level, a wide range of government and organizational policies = affect=20 user adoption and conditions of use. For example, a United Nations group = has=20 developed an index of ICT diffusion.18 = This=20 considers the indicators for Internet access in a country as including = Internet=20 users per 1000 inhabitants, adult literacy rate, cost of a 3-minute = fixed-line=20 telephone call and gross domestic product (GDP) per capita. Seen from = this broad=20 perspective, government investment and policies to boost literacy =96 as = much as=20 direct involvement in ICT policy =96 are important in ensuring that all = citizens=20 can benefit from ICT.

Health policy makers in the process of developing or=20 implementing national e-health strategies need to be able to work = effectively=20 with ICT policy makers. However, there are few precedents for = cooperation=20 between the sectors and little experience to draw on to align policy=20 interests.

Linking health and ICT policy

The potential points of influence, or entry points, = in a=20 complex environment such as ICT policy are not necessarily obvious. At a = minimum, national health policy makers need to know the basics of ICT = policy=20 objectives and approaches in order to be effective advocates for = improving=20 infrastructure, access and affordability, or for obtaining concessions = or aid=20 for the health sector. While every country is unique, national policies=20 generally set out goals and objectives for the development of the ICT = industry,=20 development of the economy and support for key sectors of the economy. = The list=20 below highlights core elements included in national ICT policy.

Core content of ICT policy

The core content of any ICT policy must include five = factors:

1. Infrastructure development. These policies = promote=20 the development, expansion, operation and increased efficiency of ICT = networks=20 at the infrastructure level. This is an area of great interest to the = health=20 sector, but not traditionally one where the sector has much influence. = Those=20 involved include governments (ministries of information technology and=20 telecommunications), the private sector (multinational corporations),=20 independent bodies (regulators) and international organizations = (International=20 Telecommunication Union).

2. Universal and equitable access to ICT = services.=20 These policies, implemented primarily at the infrastructure and services = level,=20 aim to improve the availability and affordability of ICT services. They = are=20 designed to facilitate access to ICT networks and services for all = citizens, as=20 well as for under-served groups such as the disabled and women. This = area is of=20 vital interest to the health sector, and is becoming = more open=20 to influence as policy-makers strive for more transparent and inclusive=20 policy-making processes.

3. Promotion of market competition. Policies = in this=20 area aim to stimulate ICT development and adoption by creating an = environment=20 for fair competition between providers of infrastructure and services,=20 corresponding to the infrastructure and service levels of the model. = Outcomes=20 are of great interest to the health sector, but this is not typically an = area of=20 direct influence.

4. ICT as a means of achieving national social and = economic=20 goals. These policies are designed to exploit ICT in achieving = national=20 social and economic goals, such as health, education and economic = development.=20 Policies in this area correspond to the service and user levels of the = model.=20 This is a natural and realistic entry point for the health sector in = policy=20 discussions.

5. Encouraging private sector investment. = Policies aim=20 to promote private enterprise development of ICT infrastructure and = services.=20 Policies in this area correspond to the infrastructure and services = levels of=20 the model, and are also related to overall government policies for = transparency,=20 accountability, anti-corruption and so on. Robust and sustainable = private sector=20 investment in ICT benefits the health sector, and this policy area is=20 increasingly open to sectoral advocacy and influence. There are = significant=20 variations in telecommunications investment across the world.4

Countries place different emphasis on the above = elements,=20 depending on factors such as their level of economic development, the = strength=20 and maturity of the private sector, the orientation of development = partners and=20 existing policy capacity. For example, one country may see a need for = stronger=20 emphasis on competition in services rather than on expansion of ICT=20 infrastructure. Examples of ICT policy and potential impact on the = health sector=20 are highlighted in Table=20 2.2.

Factors affecting ICT use in the health=20 sector

There are several factors that affect the use of ICT = in the=20 health sector. These include costs, access speed, education and = collaboration=20 between stakeholders.

Costs for ICT

These influence uptake in all sectors. They are = normally=20 reflected at the service level, and incorporate the costs passed on to = the user=20 from the infrastructure level. In general, two basic disparities exist = in the=20 affordability of ICT: in the basic cost of the technology and in the = cost=20 relative to per capita income. Access costs such as high Internet = service=20 provider and telephone call fees can be two to four times as high in = developing=20 countries as in developed market economies.19 = When the=20 monthly cost for Internet access exceeds the monthly income of a = significant=20 proportion of the population, its level of use will remain low.

Access speed

This directly affects cost. In nearly all = countries,=20 telephone calls are charged on a per-minute basis for telephone = mainlines, with=20 an additional access charge. Where Internet access is through a dial-up=20 connection, download times are long, and costs therefore

Table 2.2 Policy areas = related to=20 ICT
Level	Description	Examples
Infrastructure	Telecommunications and related systems	Policies that affect basic ICT = infrastructure:
		1. Telecommunications licensing = system
		2. Telecommunications operator privatization = and market=20 liberalization
		3. Spectrum allocation
		4. Internet domain management
		5. Banking and financial sector = regulation
		6. Standard setting
		7. Customs standardization
		8. Rules on taxation, tariffs, foreign = ownership of ICT=20 infrastructure
Services level	Trust and security =96 transactions that affect = use of=20 services and applications	Policies that affect business, government and = consumer=20 trust towards ICT and others online, including:
		1. Electronic signatures
		2. Data security
		3. Cybercrime, fraud and spam
		4. Privacy
		5. Intellectual property
		6. Regulation of content and freedom of = speech
		7. Consumer protection
Service level	Technology diffusion	Service and access fees, universal service = provisions,=20 and private sector and civil society access
User level	Capacity building	Policies that build the capacity to use ICT, = including=20 curriculum and materials, and technical education. For the general = public,=20 this also includes policies to ensure basic literacy, without = gender=20 difference
Overall environment	General government environment	Government structure (transparency, = independence of=20 judiciary and regulatory authorities), discrimination=20 policy

increase. The trend to using large web pages and = files is not=20 an obstacle in countries where bandwidth is increasing, but in = low-income=20 countries the long download time further increases the cost. Although=20 telemedicine can be successfully practised via low-bandwidth = connections, lack=20 of affordable broadband infrastructure significantly hampers the ability = to=20 conduct telemedicine applications where transfer of high-resolution = images is=20 required (see Chapter 13=20 and 19).

Education

This clearly affects ICT use, and international = disparities=20 are evident at the user level. The degree of technical capacity at this = level is=20 a result of long-standing government investment or under-investment in = education=20 and training, not only through initiatives such as staff development = programmes=20 and technical training in schools, but also including investment in = secondary=20 and tertiary education.

Collaboration between stakeholders

At the infrastructure and service levels, = regulations such as=20 those for importation of telecommunications equipment in emergency = situations=20 show the need for cross-border collaboration in ICT and health. Clearly, = ICT is=20 central to an effective health sector response in disaster situations, = whether=20 natural disasters or man-made (e.g. armed conflict). In the absence of = formally=20 established procedures covering disasters and emergencies, customs = clearance and=20 type-approval procedures for telecommunications equipment, allocation of = radiofrequencies and authorization for radio communications can delay=20 installation of urgently needed communications systems. For example, = regulations=20 on telecommunications equipment importation and type approval delayed = help when=20 a non-governmental organization arrived to install radio communications = in Bam,=20 Iran after a major earthquake in 2004. Lengthy national and local = customs and=20 telecommunications regulatory clearance resulted in an unnecessary and = costly=20 delay before the equipment could be installed where needed.

Legal framework, skills and protections for = a
network=20 economy

Trends in the uptake of advanced applications of ICT = such as=20 e-commerce show even greater disparities than trends in basic access to=20 computers. Many countries still lack the infrastructure, capacity and = resources=20 to develop and manage health applications, including those emerging from = e-commerce and e-government. Without these prerequisites, ICT in health = will not=20 grow significantly in developing countries. Furthermore, countries must = have the=20 skills of a networked society in order to deal with common challenges = and=20 threats. For example, security threats are growing and are becoming more = malicious, damaging and widespread, with serious implications for = countries.=20 Threats to a networked economy include spam and security violations. = These are=20 increasingly propagated from developing countries with weak laws, weak = policies=20 and inadequate security. The consequences can be severe for developing=20 countries, where awareness, protection tools, legislation and = enforcement are=20 still underdeveloped.20 = Basic=20 measures are required to ensure that security threats emanating from = developing=20 countries do not pose a threat to the Internet. Collaboration is = essential in=20 this respect, to ensure that technology resources are not diverted from = the=20 health area to deal with these security concerns.

ICT policy orientation in middle- and = high-income=20 countries

At the policy level, most high-income countries = maintain a=20 separation between government ministries in charge of telecommunications = and=20 information technology.21 = However,=20 telecommunications policy makers and regulators are increasingly = attempting to=20 incorporate the entire range of ICT in their policy domains. While = health is=20 often mentioned in the list of general benefits of ICT to society, the = specific=20 benefits of ICT for the health sector are rarely mentioned in ICT policy = statements. It is also rare to find specific actions or commitments by = ICT=20 policy makers to improve health, which is often = viewed as a=20 sector that would benefit from the latest developments in ICT. In this = context,=20 health applications often appear in policy programmes mainly to justify = the=20 importance of broadband technologies.

While the interests of the health and ICT sectors = appear to be=20 shared at conceptual levels, they are not in practice implemented to the = extent=20 that might be desired. For example, policy makers may view the health = sector as=20 a test bed for the application of high-speed telecommunications systems. = The=20 health sector would certainly benefit from the network technologies that = enable=20 transmission of the images used in medical diagnosis. It is = questionable,=20 however, whether ICT policy makers recognize these benefits and = subsequently=20 afford high priority to the health community.

Private sector ICT vendors naturally have = technology-centred=20 views and are concerned with health as a business. They are interested = in=20 digital opportunity, rather than the digital divide. They explore = business=20 opportunities to sell ICT equipment and systems. The lack of = telecommunications=20 infrastructure in rural areas may be perceived as a business opportunity = for a=20 vendor to prove the benefits of wireless broadband systems, but unless = this can=20 be profitable, it will not be sustained or implemented on a large = scale.

ICT policy orientation in low- and = middle-income=20 countries

Lack of reliable infrastructure is a severe = constraint for=20 low- and middle-income countries. The lack of adequate infrastructure to = support=20 high-quality, high-speed Internet connections is a major obstacle for = economic=20 and social development, and lack of bandwidth excludes countries from = taking=20 part in the global information society. A fundamental challenge is the = cost of=20 bandwidth, which, because of policy, regulation and technology = challenges, can=20 be up to 50 times as high as the cost of bandwidth in industrialized=20 countries.19 = Operational=20 costs on this scale put ICT out of reach for the health sector, and = represent a=20 difficult trade-off for government decision makers when considering how = best to=20 allocate health and social welfare budgets.

Provision of basic ICT services to the general public = is=20 becoming a high priority as donor-financed initiatives are beginning to = stress=20 core policy reform, incentives for private sector investment towards = providing=20 access to rural and underserved areas, development of national backbone = links,=20 and deployment of broadband and government networks.22 = This=20 long-term perspective represents a significant shift from the previous = decade of=20 project-based ICT development initiatives such as tele-centres, where = the=20 benefits to the health sector were often mentioned in the rationale for = their=20 construction but where in reality the benefits were rarely realized.

Opportunities presented by policy reform=20 processes

Policy reform processes in countries can provide an=20 opportunity for the health sector to participate in consultations when = ICT=20 policy is being developed or revised. Countries trying to improve policy = making=20 may also require training or guidelines for the public sector policy = process=20 that specifically mandate broad consultation with stakeholder groups. = For=20 example, it is evident that ICT policy makers would benefit from = understanding=20 how policy affects the technology users in all sectors. This can be achieved by means of evaluation, consultation = mechanisms or a=20 combination of the two. A government mandate for input, dialogue and = better=20 information flow provides a good starting point. At the least, the = sectors can=20 acknowledge each other=92s interests and responsibilities, although they = may not=20 share the same perspective or priorities.

Policy adjustment to meet local=20 needs

It would seem obvious that policy directions must = reflect and=20 be adapted to the local context, but this is not always the case in ICT = policy.=20 Often, basic ICT policy principles are agreed at the international = level, or=20 policies of high-income countries are simply transferred to low- and=20 middle-income countries. However, the local context =96 in terms of = local needs,=20 skills and political issues =96 has a significant effect on whether = generally=20 accepted policy reforms are adopted and put into practice. Even national = governments with the political will to drive change often face = challenges in=20 putting policies into effect, particularly where the necessary legal = framework=20 and human resources are lacking.

Opportunities for action

There is much that the health sector can achieve by = becoming=20 actively involved in ICT policy making, particularly in the long term. = But the=20 health sector may first need to build its own capacity to use evidence = and=20 information for policy and planning. A country=92s level of ICT = diffusion and=20 general policy-making capacity will show the potential areas for focus = and=20 action. The following are some examples.

A holistic approach to ICT = development

ICT is an enabler, not an end in itself, and = national ICT=20 strategy should be =91outward looking=92 and designed to ensure = effective fulfilment=20 of national development activities. ICT strategy should ensure that = there is=20 compatibility across government sectors (e.g. access and security = protocols, and=20 user interfaces). Resources should be provided for initiatives that = produce=20 significant cost savings and improve services to users.

A growing number of countries are seeking assistance = to develop=20 sector-based ICT programmes, including e-education, e-health and = e-government.=20 However, without an overall coordination mechanism at the country level, = these=20 ICT programmes may lead to sector-specific ICT infrastructure owned and = operated=20 by the relevant ministry, thereby duplicating private sector or other=20 infrastructure. A holistic approach is required, with governments = ensuring that=20 investment in ICT is coherent and sufficient to meet common needs across = the=20 sectors. The health sector may need to lobby for a more active role in = policy=20 formulation. This is possible by highlighting existing policies that = show their=20 investment and commitment to benefiting from ICT. For example, a = coordinated=20 framework may have been developed for the integration of ICT services in = district health settings. There may already be arrangements for = improving=20 managerial and technical competence to oversee e-health projects. Or = projects=20 may already be planned and funded, thereby ensuring that the health = sector will=20 obtain a substantial benefit when ICT becomes more readily available. = Not least,=20 health policy makers should be aware of the relevant policy trends in = other=20 countries and build on documented experience.

Making the case for health

ICT infrastructure, costs, human resources and=20 telecommunications regulations are four major factors that shape the = development=20 and uptake of ICT. Health policy makers must work to ensure that = policies in=20 these four areas align with health interests wherever possible. Policy = makers=20 should therefore anticipate their needs and requirements for = infrastructure and=20 bandwidth. They should propose benchmark targets for access to basic = services,=20 cost of basic services and establishment of new services for the sector. = This=20 requires more than awareness: it requires understanding and planning for = what=20 ICT can bring on a medium- to long-term basis. Policy makers should be = able to=20 articulate the drivers for access to ICT, and the potential effects of = ICT=20 policy change. High-level need and justification are important factors = in ICT=20 allocation and policy change.

Health policy makers should have an understanding of = ICT=20 solutions that can potentially be provided at low cost to meet the = sector=92s=20 needs. They must also be aware of new solutions (e.g. low-cost voice=20 communication over the Internet) that may be prohibited by = telecommunications=20 regulations in some countries. Such knowledge will provide health policy = makers=20 with alternatives in the choice of appropriate ICT policy = mechanisms.

The costs of ICT services can be expected to be an = important=20 factor for some time to come. To improve rates and services, health = policy=20 makers must be able to indicate at what level they would consider = operating=20 costs to be reasonable and sustainable. This should be based on the = funding=20 model and resources of the health sector. Across a country or set of = countries,=20 it should be possible to calculate what percentage of gross income of = the=20 subsectors could be reasonably spent on ICT services and systems and = what=20 potential funding mechanisms might be considered.

Participation in a networked economy requires = expertise and=20 resources for dealing with global technical security threats, including = viruses=20 and email spam. The sector must be able to show adequate capacity to = respond to=20 threats in a networked environment, not only to protect the sector but = also so=20 as not to pose a threat to others. Where ICT is relatively new, planning = is=20 required to develop the necessary human resources capacity, and in this = the=20 health sector must be proactive. Gaps in skills should be identified and = a plan=20 developed for training and long-term staff development and = retention.

Outlook for the future

Developing countries must boost their capacity in = ICT and=20 policy making. Basic ICT access indicators cannot demonstrate the full = extent of=20 ICT divides. Countries that are crippled by poverty, disease, foreign = debt and=20 corruption may not have the resources or the political will to invest in = ICT or=20 be considered good markets for foreign ICT investment. Countries must = boost=20 their policy-making capacity in order to ensure that their ICT policy = addresses=20 the concerns of multiple stakeholders. Even as the use of basic ICT = increases,=20 the control of advanced technology will require an environment based on = a=20 comprehensive ICT policy that reflects domestic as well as international = interests.

Table 2.3 Examples of ICT = trends and=20 their application to health
Technology trends	Applications to = health	ICT policy = issues
Broadband Internet	Distance delivery of health care services: = consultations,=20 transmission of prescription and purchase of medicines, using = text, still=20 and mobile pictures, and voice	= Technology=20 standards
		= Privacy=20 protection
		=20 Costs
		= Geographical=20 availability of broadband Internet
Digitization	Video and pictures	= Technology=20 standards
	Electronic databases and memory chips as = patient record=20 archive	= Privacy=20 protection
Wireless communications technologies	Mobile communications: health anywhere from=20 everywhere	=20 Costs
		= Geographical=20 availability of wireless = communication

For the future, international and domestic divisions = in ICT use=20 will be shaped by a number of factors that have the potential to widen = or close=20 the gap. These include the following:

new = technology=20 solutions, such as automatic translation services and inexpensive = wireless=20 phone-based Internet;

increasing = global=20 coverage of satellite systems and lower costs for access;

concerted = action to=20 diffuse ICT and help people use it effectively;

broad = economic and=20 trade policies that will spur integration of ICT into the global economy = as a=20 key engine for growth;

improved = governance=20 and standards setting and the need for evolving models to improve = inclusion and=20 representation of stakeholders.

Boosting government awareness and capacity is = central to=20 achieving equitable, affordable ICT for the health sector in all = countries. The=20 health sector has an important role. Those involved can take concrete = action as=20 follows:

actively = participate=20 in the ICT policy debate to improve awareness and understanding of the = needs of=20 the sector;

emphasize = that=20 benefits to the health community also benefit the public at large;

educate = ICT vendors=20 to develop equipment and systems that meet the needs of developing = countries,=20 i.e. low cost, durable and easy maintenance;

work with=20 non-governmental organizations and civil society, who have an interest = in=20 improving ICT access for the public;

learn from = each=20 other, in order to improve input and participation in ICT policy debate = on such=20 issues as costs, infrastructure development, access to the Internet, = content in=20 local languages and privacy protection.

Conclusion

ICT is fundamental to providing effective and = efficient health=20 services and systems. These technologies can improve workforce and = workplace=20 efficiency and boost quality of care by reducing medical errors, = reducing costs=20 and improving safety. They provide networks and tools for learning, = research and=20 practice. They enable access to information, products and advice for = disease=20 prevention and management, and will be essential to the move to = personalized=20 health and care in the future.

There are many opportunities for health policy makers = to=20 influence the ICT policy process. Their chances of success will be = improved by=20 understanding how ICT can benefit health. Health policy makers must be = effective=20 advocates for health concerns and must be able to enumerate the effects = of ICT=20 policies on health. For policy makers committed to improving national = health=20 systems, participating in the national ICT policy-making process is = essential to=20 ensure that national ICT policy, when implemented, will meet the = interests of=20 the health sector.

Acknowledgements

I thank Ms Yoshiko Kurisaki, SITA, Geneva, = Switzerland for=20 preliminary discussions and Mr Shubhabrata Roy, Microsoft, UK, for his=20 assistance with data and graphics.

References

1.=20 United Nations Statistical Division. Millennium Development Goals = and=20 Targets. Available at: = unstats.un.org/unsd/mi/pdf/mdglist.pdf.

2.=20 International Telecommunication Union. World Summit on the = Information=20 Society Tunis Commitment. Available at:=20 www.itu.int/wsis/docs2/tunis/off/7.html.

3.=20 United Nations Conference on Trade and Development. The Digital = Divide: ICT=20 Development Indices 2004. Available at:=20 www.unctad.org/en/docs/iteipc20054_en.pdf.

4.=20 International Telecommunication Union. World Telecommunication = Indicators=20 Database 2006. Available at: = www.itu.int/publ/D-IND-WTID-2006/en.

5.=20 World Health Organization. The World Health Report 2004 =96 = Changing=20 History. Available at: www.who.int/whr/2004/en/index.html.

6.=20 Council of the European Union. Legislative Acts and Other = Instruments.=20 Council Resolution on the Implementation of the eEurope 2005 Action = Plan=20 (Document 5197/03). Brussels: European Union, 2003.

7.=20 World Health Organization. The World Health Report 2006 =96 Working = Together=20 for Health. Available at: www.who.int/whr/2006/en/index.html.

8.=20 European Commission, Information Society and Media. The Networked = Future:=20 Living in a World of Converging Information and Communication = Technologies.=20 Luxembourg: European Communities, 2005.

9.=20 Picot J. MBTelemedicine Evaluation Final Report. Volume 1: = Information and=20 Findings. Report to the Canadian Health Infostructure Partnership = Program,=20 Government of Canada, 2003.

10. Ball MJ, = Garets DE,=20 Handler TJ. Leveraging IT to improve patient safety. In: Yearbook of = Medical=20 Informatics 2003. Stuttgart: International Medical Informatics=20 Association/Schattauer, 2003: 1=966.

11. = Commission of the=20 European Communities. Communication from the Commission to the = Council, the=20 European Parliament, the European Economic and Social Committee and the=20 Committee of the Regions, June 2005. Brussels, European Union, = 2005

12. Fox S. = Health=20 Information Online. Available at:=20 www.pewInternet.org/pdfs/PIP_Healthtopics_May05.pdf.

13. World = Health=20 Organization. World Health Report 2007 =96 A Safer Future: Global = Public=20 Health Security in the 21st Century. Available at:=20 www.who.int/whr/2007/en/index.html.

14. Kamal A. = The=20 Law of Cyber-space. Geneva: United Nations Institute of Training = and=20 Research, 2005.

15. Dzidonu = CK. Demand=20 and supply for access and connectivity: the case of Ghana. In: Low = Cost=20 Access and Connectivity: Local Solutions. New York: United Nations = ICT Task=20 Force, 2003: 1=9620.

16. United = Nations=20 Economic and Social Council, Economic Commission for Africa. National = knowledge=20 systems and the status of information access policies in Africa=20 (E/ECA/CODI/4/50). Paper presented at the Fourth Meeting of the = Committee on=20 Development Information, Addis Ababa, Ethiopia, April 2005.

17. Wolcott = P, Press L,=20 McHenry W et al. A framework for assessing the global diffusion of the = Internet.=20 J Assoc Inform Syst 2001; 2: 1=9650.

18. United = Nations=20 Conference on Trade and Development. The Digital Divide: ICT = Development=20 Indices 2004. New York: United Nations, 2005.

19. Jensen M. = Interconnection Costs. Available at:=20 www.apc.org/en/pubs/issue/accessibility/all/interconnection-costs.

20. = International=20 Telecommunication Union. ITU Activities Related to = Cybersecurity.=20 Available at: www.itu.int/cybersecurity.

21. = Organisation for=20 Economic Co-operation and Development. Regulatory Reform as a Tool = for=20 Bridging the Digital Divide. Paris: OECD, 2004.

22. Hamilton = P.=20 Identifying Key Regulatory and Policy Issues to Ensure Open Access = to=20 Regional Backbone Infrastructure Initiatives in Africa. Washington, = DC:=20 World Bank, 2004.

3 Telemedicine in developing countries: = Perspectives from=20 the Philippines

Alvin B Marcelo

Introduction

The University of the Philippines Manila National = Telemedicine=20 Center was established in 1998 to investigate the use of information and = communications technology (ICT) to improve health care delivery for all=20 Filipinos. The Center is based at the Philippine General Hospital. It = manages=20 referrals from more than 40 doctors in remote areas around the country,=20 connecting them to more than 600 experts at the Philippine General = Hospital. In=20 implementing e-health and telemedicine, the National Telemedicine Center = chose=20 an approach based on community involvement as well as technology. Three=20 different case studies are described below that demonstrate different = aspects of=20 this strategy. The case studies are CHITS, the E-Learning for Health = Project and=20 the SMS Telemedicine Project.

The approach to implementation consisted of three = distinct=20 steps:

1. The human experience: start from where the people = are.

2. The technological opportunity: identify = appropriate,=20 available, accessible and culturally acceptable technologies.

3. The sustenance factor: embed the technology into = the local=20 fabric.

The human experience

Although technology offers benefits in terms of = applying new=20 processes and approaches to problem-solving, the fact is that most = health=20 interventions are only as effective as their ability to become embedded = in=20 routine activity. This means that if e-health implementations are = approached=20 from a purely technical standpoint it will invariably fail to realize = their full=20 potential.

The essence of the human experience is communication = and=20 interaction. The National Telemedicine Center has observed that the = benefits for=20 communities of e-health and telemedicine occur when the technology = presents=20 itself (a) as an enhancement to existing human relationships that have = been=20 established through conventional routes or (b) as a = solution=20 to a long-felt community need. In either case, the Center=92s experience = has shown=20 that technology has higher chances of sustaining itself in areas where = mature=20 human relationships and interactions already exist.

My experience with the Community Health Information = Tracking=20 System1 = (CHITS) has=20 allowed me to observe a highly technical training programme evolving = into one=20 that is less technology based and more community oriented and = dialectical.=20 During the initial CHITS training, much time was wasted in teaching = elderly=20 health workers how to use a mouse and to type on a keyboard. At the end = of the=20 training sessions, participants still appeared to be afraid of = accidentally=20 damaging the computer. Post-training interviews revealed that the health = workers=20 never became comfortable with the technologies that were being = introduced (the=20 PC and the electronic medical record application).

Community Health Information Tracking=20 System

CHITS was funded in 2004 by the International = Development=20 Research Centre of Canada and subsequently by the United Nations = Development=20 Programme (UNDP). The aim was to develop an integrated disease = surveillance=20 system. CHITS was developed in close consultation with village health = workers to=20 best identify their needs. The result was an open-source application for = the=20 village health centre that combined the features of an electronic health = record=20 and clinic appointment system while also integrating modules for = national health=20 programmes.

CHITS was a starting point for the integration of = information=20 systems. Through CHITS, community-based health information was made = available=20 not only to public health agencies requiring community level information = but=20 also to the community that generated the information. It enabled the = community=20 to use this information for local decision-making.

Currently, CHITS is in use in 12 health centres in two = cities=20 and two provinces in the Philippines. It has made the work of village = health=20 workers easier, since information is entered only once during a patient=20 consultation and can then be used to generate the different reports that = need to=20 be submitted to the Department of Health. Since data are stored = electronically,=20 it is now easier to access and consolidate information, and there is = less risk=20 of data loss. More timely reports allow community leaders to make better = decisions for their people.

There are approximately 100 000 transaction records = from the 12=20 health centres presently using CHITS. The information is stored in = databases=20 using simple data elements patterned after the Department of Health. = Access is=20 limited to authorized personnel, who undergo a two-day electronic health = record=20 training prior to using the system. In this training programme, the = ethics of=20 health information management are taught with special attention to the=20 responsibility and security required for digital data. All data are = owned by the=20 relevant health centre, which also controls access. The data can be = extracted=20 using open-source software tools.

In the light of early experience, revisions in the = training=20 programme were made. Foremost among the changes was the shift from a = highly=20 structured training programme on how to use the keyboard and mouse to a = less=20 strict, more fun approach to using the interfaces by allowing the health = workers=20 to play games on the computer. The trainers = discovered that=20 health workers were often afraid of the new =91formal=92 skills that = they needed to=20 acquire, but were more relaxed (albeit sometimes fiercely competitive) = when=20 asked to beat each other in a game of solitaire. So, instead of coercing = the=20 participants into a strict regimen of clicking and copy-pasting, they = are given=20 time to develop confidence in the use of the keyboard and the mouse = through=20 simple games. The game orientation removes the fear that they have to = perform=20 well in a short period of time. This is what is meant by starting from = where the=20 people are. A recognition of the cultural aspects of community life is = important=20 in starting them off into a new direction such as computerization and=20 automation.

In 2006, CHITS was chosen as one of the key = e-government=20 projects by the APEC Digital Opportunity Center in Taiwan.2 It = was also a=20 finalist in the 2006 Stockholm Challenge.3

The technological opportunity

The process of understanding local cultures and = processes,=20 respecting the local experts, and analyzing their thought processes can = often be=20 frustrating. However, it is essential if external technology is to be = embedded=20 into the community=92s way of life. Once the community has been = understood, the=20 technologies that are available and appropriate can be determined. The = National=20 Telemedicine Center=92s experience with its E-Learning for Health = Project has=20 demonstrated the importance of this step.

E-Learning for Health = Project

The migration of health professionals from rural = areas in the=20 Philippines has progressed to the point that many municipalities are = unable to=20 provide regular training to community health care volunteers. Many of = these=20 under-served communities are also in hard-to-reach, remote areas, and = travel=20 costs can be high. With support from USAID, the National Telemedicine = Center=20 developed four video modules about common topics relevant to the = management of=20 disease in the community:

community = management=20 of accidental childhood poisoning

community = management=20 of stroke

community = management=20 of tuberculosis

community=20 introduction to the avian influenza threat.

These video modules last 7=9610 minutes each and are = narrated in=20 the vernacular with English subtitles. The audiences are community = health care=20 volunteers in remote communities. After the video showing, an = interactive=20 question and answer session is established between the expert in Manila = and the=20 volunteers using the best available technology (ranging from = videoconferencing=20 to mobile phone calls). Various telecommunication media have been = employed for=20 the educational sessions which are held in various locations (Figure = 3.1):

childhood = poisoning=20 between Manila and Basak Pardo, Cebu, using broadband Internet (Figure = 3.2)

3DImage=20

Figure 3.1 Locations of educational=20 sessions

3DImage=20

Figure 3.2 An expert participating = in a health=20 worker=92s meeting via videoconferencing

stroke = between=20 Manila and Nueva Vizcaya, using cellphones

avian = influenza and=20 tuberculosis between Manila and Roxas City and Tapaz, Capiz Province, = using=20 Internet videoconferencing.

One reason for the success of this teaching model = was the=20 familiarity of the audience with the lecture format. We were able to = elicit=20 participation from the audience by providing them with access to an = expert in=20 Manila. There were several benefits. First, there were cost and time = savings=20 from travel by not having to transport the expert to a remote area. = Second, the=20 expert could serve several communities in a single session. The audience = were=20 able to receive updates using a novel method that did not require them = to=20 establish new skills. In all cases, the local participants were given = the=20 opportunity to participate and ask questions directly of the expert = using the=20 vernacular.

In the Philippines, massive migration of doctors and = nurses has=20 resulted in a lack of trainers in the public health sector. Even where = there are=20 many community health volunteers, there are not enough trainers and = leaders to=20 provide them with the requisite knowledge.

Visiting the under-served communities has made the = staff of the=20 Center aware of what technologies are available. Televisions and video = CD=20 players can be found in almost all communities. In populated areas, = there is=20 invariably mobile phone coverage, so that voice calls and/or a = short-message=20 service (SMS) are also available.

The E-Learning for Health Project has shown that, by = using=20 locally available technology and the best available bandwidth, it is = possible to=20 establish interaction between a group of health care volunteers (in a = remote=20 community) and an expert (in an urban area). Voice calls were found to = be most=20 effective, although participants also appreciated videoconferencing. The = community members were keen to accept the new modality, because it = employed=20 technologies that were already familiar to them. Pretests and post-tests = given=20 to participants revealed that they were able to gain knowledge from the=20 e-learning activity.

The sustenance factor

Stand-alone, intermittent, expert-driven events = (such as the=20 E-Learning for Health Project and CHITS) are easy to implement, but are = they=20 sustainable? In order to achieve permanence, e-health and telemedicine=20 applications must be embedded into the local fabric of the = community.

How, then, do we overlay the technologies (step 2) = over the=20 local issues (step 1) to ensure that the technical solution finds a home = in the=20 heart of the community? E-health should be considered as another = community=20 activity that will need to involve discussions, arguments and = deliberations.=20 E-health should thus become the vehicle for more rapid and more = structured=20 community development through enhanced communications and process = documentation.=20 This becomes more apparent with the use of mobile phones for = health-related=20 concerns such as announcements for community meetings, reminders for=20 vaccinations and prenatal check-ups. It also involves gathering the = health=20 volunteers and workers regularly to attend e-learning sessions on = community=20 health development.

In one high-profile government-funded project, the = BuddyWorks=20 Community Partnership in Delivering Telemedicine Services, remote sites = were=20 provided with workstations and broadband Internet connections to allow = them to=20 refer difficult cases to experts in a central facility. A total of 10 = facilities=20 in four provinces was involved. However, despite the substantial = investment,=20 referrals from the remote sites did not occur. Analysis revealed a = workflow that=20 prevented the users from assimilating desktop Internet technologies for=20 communicating clinical dilemmas. In the proposed system, the remote = physician=20 needed to log on to a computer with Internet access, go to the agreed = website=20 portal, enter the relevant clinical data and wait for the response of an = expert=20 =96 who would probably be busy with his or her own patients at the time. = The=20 process had so many steps that the risk of a failed transaction was very = high.

SMS Telemedicine Project

In response, the workflow was revised to allow the = doctors to=20 communicate via SMS. Most doctors already owned a mobile phone. Using = SMS, they=20 were able to communicate more effectively. It was then decided to = supplement the=20 existing network by providing modest prepaid SMS allowances to the = doctors and=20 offering them free conference call services for voice-based referrals. = This=20 system has proved to be sustainable and effective. During a 6-month = period, over=20 300 referrals were received from 44 doctors in remote areas.

Conclusion

It is widely accepted that all societies, especially = those of=20 developing countries, can build more cohesive communities through the = primary=20 health care approach. Telemedicine and e-health have a great potential = to=20 facilitate service delivery in primary care. For example, rural health = workers=20 commonly suffer from inefficient, paper-based recording systems. CHITS, = based on=20 free and/or open source software and SMS, provided a more effective=20 alternative.

At the core of any telemedicine service is an = electronic health=20 record. This is how CHITS plays a role in telemedicine =96 by providing = a=20 consistent view of the patient=92s records. The current telemedicine = services in=20 the Philippines are simple enhancements to existing trust structures. By = using=20 SMS and mobile phones, the National Telemedicine Center is able to = provide=20 access to experts for patients who would not otherwise have been able to = consult=20 them. The use of SMS technology has increased the area of coverage of = the=20 Center.

The challenges that plague the Philippine system are = the=20 continuing loss of health professionals from internal and external = migration. As=20 more and more health workers seek work in other countries and rural = physicians=20 move from rural to urban practices, the number of municipalities without = doctors=20 will increase. Establishment of an efficient and effective referral = network,=20 based on mobile phone technology, is a key component in mitigating the = effects=20 of this migration. The faster the trust relationships between the remote = doctors=20 and physicians are established, the quicker telemedicine services can = take hold=20 in the relevant communities.

References

1.=20 Tolentino H, Marcelo A, Marcelo P, Maramba I. Linking primary care = information=20 systems and public health information networks: lessons from the = Philippines.=20 Stud Health Technol Inform 2005; 116: = 955=9660.

2.=20 APEC Digital Opportunity Center. Available at: www.apecdoc.org.

3.=20 Stockholm Challenge. Available at: www.stockholmchallenge.se.

4 Information technology for primary health care = in=20 Brazil

Elaine Tomasi, Luiz A Facchini, Elaine = Thum=E9, Maria FS=20 Maia and Alessander Osorio

Introduction

Decision making in public health depends on the = availability=20 of reliable information, which is generated, analyzed and disseminated = by=20 information systems.1,2 = However, most=20 national health information systems lack the information needed to = address=20 health inequities, namely, reliable, longitudinal data that links = measures of=20 health with measures of social status at the individual or small-area = level.

At all levels of health care, particularly in primary = care,=20 there is a consensus concerning the usefulness of information = technology,=20 especially for promoting greater efficiency in management = processes.3,4 = Although=20 studies evaluating the impact of such technologies on health are still=20 rare,5,6 most = authors=20 agree that there are positive effects from these systems and that they = can be=20 improved further through regular monitoring.

Low levels of computerization in primary health care = are very=20 common. Furthermore, many papers stress the need for continued = motivation and=20 training for all team members as a prerequisite for the success of any=20 initiative in this area.7,8 It = may be=20 pertinent here to quote the reflections by Branco9 on = the=20 significance of training, that is, the amplification of knowledge:

=85 knowledge of the logic behind health = information=20 production and flux must be provided to all persons involved, and should = include=20 an understanding of the goals of the systems to which they have access, = and of=20 the possibilities for use of the information produced =85

Martinez et al10 = analyzed=20 communication and information needs in primary health care in rural = areas from=20 Peru and Nicaragua. They found three main factors related to the = inefficiency of=20 the health systems: poor infrastructure, a lack of information systems = and=20 deficiencies in the training of health professionals. Other authors have = emphasized the need to incorporate good-quality health care data from = local=20 levels into national databases.11=9614 = Similarly,=20 Gething et al15 = stated that=20 the value of information systems in health is to = point out the=20 needs and priorities at both national and local levels, but the process = of=20 feeding data into the systems often fails.

Another source of problems is the contrast between the = availability of information technology (IT) at the central level of = health=20 system management and its shortage elsewhere, particularly in primary = care.=20 There is often pressure for new data, increasing the time required for=20 collection, with no assurance about its analysis, dissemination and = usefulness=20 in decision making. The great quantity of data about each patient, = recorded by=20 health professionals, seems to have little meaning in their daily=20 activities.16 We = believe=20 that all of these factors contribute to the current situation =96 but = especially=20 the lack of motivation of most health care staff and the poor = integration=20 between health care and IT professionals.

Establishing IT in the health services, especially in = primary=20 care, is a challenge for the advance of information systems, not only in = the=20 smaller and poorer towns. In bigger cities, the central levels of the = health=20 system generally have good access to IT resources, but the recording of = the=20 actions of the major part of the health services is still performed=20 manually.16

There are few reports in the literature about the = experience=20 with the development and use of computerized systems in primary care. = Herman et=20 al17 = described the=20 Community Health Information Tracking System (CHITS) in the Philippines, = which=20 has the objective of integrating local and national level information = and=20 pointing out =91islands=92 in the information systems and a great amount = of repeated=20 work in the management of such systems (see also Chapter 3). = Aspects related=20 to access to data from different information systems, and their use and = control,=20 should be considered, including their creation, implementation, = monitoring and=20 evaluation.18

IT in primary care in Brazil

Two recent initiatives from the Brazilian government = are the=20 National Information Policy on Informatics in Health (NIPIH/PNIIS)19 and = the=20 National Telemedicine Programme in 2006.20 The = NIPIH=20 focuses on health work, on the user and on the electronic health record. = The=20 proposals are underpinned by standards to represent and share health=20 information, the connectivity structure, the training of human resources = in the=20 information systems in health, and, above all, the guarantee of privacy = and=20 confidentiality of the information.

National Telemedicine = Programme

Telemedicine activity currently involves about 30 = universities=20 and research institutes in 9 of the 27 Brazilian states. The pilot = project in=20 telemedicine for primary care involves the installation of 900 PCs, = mainly for=20 decision support. These PCs are connected to a wide area network, and = can also=20 be used for videoconferencing. They have an electronic medical record, = which can=20 be shared with other units. Priority is being given to cities where = there is a=20 family health programme, a population of less than 100 000 and = geographical=20 barriers to health care. The Ministry of Health, together with=20 the Ministry of Education, has been investing in distance learning for = training=20 and continuing education of health professionals.

National information = systems

The information systems available in Brazil consist = of large=20 databases of statistics. These include births, deaths and a disease = surveillance=20 system. There are also tools for the management of outpatient and = hospital=20 services.

The only computerized health information system used = in family=20 health centres is the Primary Care Information System. This is the = source of=20 information, and provides most of the tools and the forms completed by = the=20 primary care team. Most health professionals recognize it as a tool for=20 improving the epidemiological profile, but it is underutilized. = According to the=20 staff concerned, this underutilization is due to various limitations of = the=20 system, to a lack of knowledge and lack of preparation for exploring its = full=20 capacity, to a lack of training and to a lack of incentive to use it for = data=20 analysis. The system has weaknesses, but some professionals also have=20 difficulties in manipulating it both regarding the input of data and in=20 producing reports.

Data collection is fragmented, with no connection with = health=20 policies to facilitate the planning and decision making. The data = collection and=20 transfer mechanisms generate repeated work and reduce efficiency in the=20 management of information.19 The = system=20 does not allow integration with other systems, and cannot identify users = and=20 show their links to health services. For this, a National Health Card is = being=20 implemented. However, because of the magnitude of the investment = required,=20 progress has been slow.

The proliferation of information systems should be = highlighted.=20 For each need, sector, disease or event, new software is created, = implying high=20 costs for development and maintenance, and a lack of standardization and = interoperability. According to Cohn et al,12 = there is=20 little use of information from the large databases in Brazil, especially = in=20 small towns. The full potential of the information has yet to be = realized.12,21

Telemedicine

Separate from the National Telemedicine Programme, = the BH=20 Telemedicine Project was implemented in 2003. The aim was to promote the = continuing education of health workers in primary care units, as well as = contributing to the modernization of the public health system. The BH=20 Telemedicine network connects primary care centres to the Federal = University of=20 Minas Gerais teaching units, with activities in the fields of medicine, = nursing=20 and dentistry. The network uses videoconferences for continuing = education, and=20 teleconsulting between specialists and staff at the primary care centres = for=20 second opinions and for discussion of clinical cases. The = videoconferencing=20 network operates at 128 kbit/s.

The telemedicine network has been implemented in 121 = primary=20 care centres. About 1500 teleconsultations per year occur between = specialists=20 and staff at the primary care centres. In 2006, there were 75 = educational=20 videoconferences, including medical, nursing and dentistry areas, = involving more=20 than 5000 participants. The activities have resulted in more effective=20 participation of the oral health group, followed by nurses and finally = by the=20 physicians.

The project has been evaluated by two groups. The = results showed=20 better outcomes for the cases discussed, with about 70% of patients = staying in=20 basic units, with no need for referral to a specialist. There was also a = reduction of 71% in the number of patients who needed to travel to the = Clinics=20 Hospital of Belo Horizonte to be seen.

Computerized tools

In 2005, a survey was conducted to characterize = primary care=20 and evaluate differences in the effectiveness of services according to = the model=20 of care =96 family health or traditional.16 = Under the=20 Family Health Programmes (FHP), teams are composed of a doctor, a nurse, = a nurse=20 technician and about five community health agents. These teams are = responsible=20 for supervising a set number of families (about 1000) living in a = particular=20 area. The teams undertake work involving health promotion, prevention, = recovery=20 and rehabilitation. In the traditional model, teams do not include = community=20 health agents and do not have their activities focused on health = promotion and=20 disease prevention.

The survey enrolled 41 municipalities of more than 100 = 000=20 inhabitants in the south and north-east regions of Brazil, which = represented=20 approximately 20% of these size municipalities in the country. There = were=20 systematic differences between the demographic and socioeconomic = indicators from=20 the south and north-east of the country. In the south, the average human = development index (HDI), life expectancy, number of literate people and = homes=20 with tap water supply were higher than in the north-east. North-east=20 municipalities showed a higher proportion of poor people (41% vs 17%), = while the=20 southern municipalities showed a higher proportion of elderly citizens = (9% vs=20 7%).

Information about the 236 primary care centres was = obtained by=20 questionnaire: 4749 health workers were studied. Among these, 11% were=20 physicians, 7% nurses, 8% professionals with another college degree, 18% = nursing=20 assistants, 23% other professionals with a high school degree and 33% = community=20 health agents. One-third of the primary care centres had a computer = (35%): 40%=20 in the south and 29% in the north-east. Considering the care model, 39% = of the=20 family health services had a computer, as opposed to only 25% of the = traditional=20 services (Table = 4.1).=20 Only 11% of the primary care centres had Internet access: 17% in the = south=20 region and 5% in the northeast region. The traditional services had more = Internet access (14%) than the family health services (9%) (Table = 4.2).

About 20% of the health workers mentioned their use of = computers=20 for professional activities. This use was almost 50% among physicians, = nurses=20 and other professionals with a college degree, and a little more than = 10% among=20 nursing technicians, community health agents and other members of the = teams who=20 had a high school education. The use of computers in the primary care = centres=20 was even less frequent, being mentioned only by 8% of the professionals = (Table = 4.3).

Depending upon the region, the use of computers in = health=20 centres was 14% in the south and 5% in the north-east. Depending upon = the care=20 model, it was 10% in family health services and 6% in the traditional = centres=20 (Table = 4.4).

Table 4.1 Microcomputers in = primary=20 care services according to the model of health care and = geographical=20 region (n =3D 236)
	South (%)	North-east (%)	Total (%)
Family health	46	33	39
Traditional	30	16	25
Total	40	29	35

Table 4.2 Access to the = Internet in=20 primary care services according to the model of health care and=20 geographical region (n =3D 236)
	South (%)	North-east (%)	Total (%)
Family health	16	4	9
Traditional	17	10	14
Total	17	5	11

Table 4.3 IT use by primary = care=20 workers according to location of access (n =3D = 4749)
	In home or primary health care unit=20 (%)	Only in primary health care unit=20 (%)
Community health agents	3	6
Other assistants	4	10
Nurse assistants	6	7
Nurses	34	16
Other professionals	35	11
Doctors	47	8
All	14	8

Table 4.4 Use of computers by = primary=20 care health workers according to model of health care and = geographical=20 region (n =3D 4749)
	South (%)	North-east (%)	Total (%)
Family health	15	6	10
Traditional	12	3	6
Total	14	5	8

PACOTAPS

PACOTAPS is a tool for decision making. The = objective of the=20 PACOTAPS software is to assist health managers and teams with = information about=20 population characteristics and health demands.22 The = software=20 provides a structure to receive data about the contacts and procedures = performed=20 at primary care centres. The origin document is the = Outpatient=20 Contact Form, which is completed by the health team and signed by the = user. Once=20 the form has been completed, the data are typed in using a module called = users contact with the services.

PACOTAPS includes lists of professionals, groups and = procedures=20 that are standardized by the Outpatient Information System. For the=20 identification of the diagnosis, PACOTAPS provides the application = PESQCID,23 = which allows=20 a guided consultancy to the International Classification of Diseases = (ICD-10).24 = Thus, using=20 the system it is possible to find out, for a certain period of time, the = distribution of patients by age and gender, the main diagnosis and the=20 proportion of referrals.

Training

About 400 primary care workers from the 41 cities = under study=20 were trained in monitoring and evaluation through practice exercises in = a=20 computer laboratory, in two regional workshops. The participants could = install,=20 become familiar with and use PACOTAPS, with emphasis on the module = users=20 contact with the services. Thus, they were able to understand its=20 usefulness for the daily activities of primary care centres, and in = municipal=20 health management. The simplified data entry and the immediate = availability of=20 reports were very attractive, as these are requirements often mentioned = by=20 health workers. The training aims to make health workers aware of the = need to=20 produce accurate and valid information. At the end of training, each=20 municipality received a CD for installation of the software and the = application=20 manual.

Survey results

In the PROESF study, all the 26 019 user contacts = with the=20 primary care centres were recorded in PACOTAPS. Information was = collected about=20 the users=92 profiles (age, gender and health problems), the procedures = performed=20 and the referrals. One-third of the contacts (35%) were for women = between 15 and=20 49 years old, i.e. of reproductive age. The second largest group was for = people=20 60 years of age or older (19%) and the third largest group was children = below 5=20 years old (15%).

Every user can receive one or more procedures at each = contact.=20 For example, a child may receive an immunization and also have a medical = consultation for diarrhoea; an elderly person may have his or her blood = pressure=20 checked, have a medical consultation for back pain and receive his or = her=20 medication; a pregnant woman may have her weight checked, have a medical = consultation for urinary infection and be attended to by the social = worker for=20 receiving a benefit. Therefore, the number of procedures is usually = higher than=20 the number of people attended to. In this sample, more than 37 000 = procedures=20 were analysed.

Although nurses and nurses=92 assistants comprised 25% = of the=20 teams, they performed more than half of the procedures (53%). The = physicians,=20 who represented 11% of the professionals, accounted for 26% of the = procedures.=20 Almost 70% of the procedures were related to factors that influenced the = health=20 status and the contact with the services, such as prenatal care and = paediatrics,=20 immunization and screening tests. After this, health problems related to = the=20 digestive system (7%), circulatory system (4%) and respiratory system = (4%) were=20 observed more frequently.

Although 23% of the records did not have information = about=20 referrals, it was observed that in 70% of the contacts there was no need = to=20 refer the user to other care levels or to request diagnostic tests.

Conclusions

Primary care plays a major role in producing better = health=20 care for all people, particularly in developing countries. Efforts are = now being=20 directed towards the improvement of different models of care. As in = other=20 places, in Brazil, family health care is becoming a successful equity = promotion=20 effort, because it is more widely present in poorer regions with a more=20 vulnerable population. Despite limitations that are common to primary = care, the=20 family health programme does more for whoever needs more.

The experience of the BH Telemedicine implementation = provides=20 guidance for the future:

potential = for=20 innovation in the public network

standards = governing=20 the interaction between teaching and the assisting practice of the = health=20 services

= improvements in the=20 assisting structure, with possibilities of reduced costs and better = structuring=20 of a multidisciplinary project of telemedicine.

The main challenges regarding IT for primary care = are:

1. To improve IT in primary care centres, rather than = at the=20 central levels of health system management.

2. To estimate standardization and compatibility = between=20 national health information systems, especially through web-based tools = rather=20 than the production of local software or information systems.

3. To promote a wide professional training in IT as a = strategy=20 to facilitate its use in decision making for clinical practice, and to = monitor=20 and evaluate health programmes, focusing on people rather than on=20 technology.

Overall, this will require greater investment in IT = and=20 telecommunications directed towards the basic health units. This = investment=20 should be made by municipalities, but currently there are other = priorities in=20 the country=92s public health system, and resources are scarce.

References

1.=20 AbouZahr C, Boerma T. Health information systems: the foundations of = public=20 health. Bull World Health Organ 2005; 83:=20 578=9683.

2.=20 Magruder C, Burke M, Hann NE, Ludovic JA. Using information technology = to=20 improve the public health system. J Public Health Manag Pract = 2005;=20 11: 123=9630.

3.=20 Kukafka R. Public health informatics: the nature of the field and its = relevance=20 to health promotion practice. Health Promot Pract 2005;=20 6: 23=968.

4.=20 OPS (Organizaci=F3n Panamericana de la Salud). Sistemas de = informaci=F3n y=20 tecnologia de informaci=F3n en salud: desafios y soluciones para = Am=E9rica Latina y=20 el Caribe. [Information Systems and Information Technology in = Health:=20 Challenges and Solutions for Latin America and the Caribbean.] = Washington,=20 DC: OPS, 1998.

5.=20 Macinko J, Guanais FC. Selected Annotated Bibliography on Primary = Health=20 Care in the Americas. Pan American Health Organization=92s Primary = Health=20 Care Working Group, 2004. Available at:=20 www.opas.org.br/servico/arquivos/Sala5520.pdf.

6.=20 Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: = systematic=20 review of published articles on primary care computing during 1980=9697. = BMJ 2001; 322: 279=9682.

7.=20 Magalh=E3es CAS. An=E1lise da resist=EAncia m=E9dica =E0 = implanta=E7=E3o de sistemas de=20 registro eletr=F4nico de sa=FAde. [Analysis of Medical = Resistance to the=20 Introduction of Systems for Electronic Health Records]. Rio de = Janeiro:=20 Funda=E7=E3o Get=FAlio Vragas, 2006.

8.=20 Nobel J. Changes in health care: challenges for information system = design.=20 Int J Biomed Comput 1995; 39: 35=9640.

9.=20 Branco MAF. Informa=E7=E3o e tecnologia: desafios para a implanta=E7=E3o = da Rede=20 Nacional de Informa=E7=F5es em Sa=FAde. [Information and technology: = challenges to=20 developing a national health information network.] Physis: Rev Saude = Coletiva 1998; 8: 95=96123.

10. Martinez = A,=20 Villarroel V, Seoane J, del Pozo F. Analysis of information and = communication=20 needs in rural primary health care in developing countries. IEEE = Trans Inf=20 Technol Biomed 2005; 9: 66=9672.

11. Ali M, = Park JK, von=20 Seidlein L et al. Organizational aspects and implementation of data = systems in=20 large-scale epidemiological studies in less developed countries. BMC = Public=20 Health 2006; 6: 86.

12. Cohn A, = Westphal=20 MF, Elias PE. Data and the process of formulating health policies. = Rev Saude=20 Publica 2005; 39: 114=9621.

13. Gladwin J, Dixon RA, Wilson TD. Implementing a = new health=20 management information system in Uganda. Health Policy Plan = 2003;=20 18: 214=9624.

14. Viacava = F, Dachs=20 JNW, Travassos C. Os inqu=E9ritos domiciliares e o Sistema Nacional de = Informa=E7=F5es=20 em Sa=FAde. [Household surveys and the National Health Information = System.]=20 Cienc Sa=FAde Coletiva 2006; 11: = 863=969.

15. Gething = PW, Noor=20 AM, Gikandi PW et al. Improving imperfect data from health management=20 information systems in Africa using space=96time geostatistics. PLoS = Med=20 2006; 3: e271.

16. Facchini = LA,=20 Piccini RX, Tomasi E et al. Monitoramento e avalia=E7=E3o do Projeto de = Expans=E3o e=20 Consolida=E7=E3o da Sa=FAde da Fam=EDlia: relat=F3rio final. Pelotas: = UFPel, 2006.=20 Available at: www.epidemio-ufpel.org.br/proesf/index.htm.

17. Herman T, = Marcelo=20 A, Marcelo P, Maramba I. Linking primary care information systems and = public=20 health vertical programs in the Philippines: an open-source experience. = AMIA=20 Annu Symp Proc 2005: 311=9615.

18. McGrail = KM, Black=20 C. Access to data in health information systems. Bull World Health=20 Organ 2005; 83: 563.

19. Brasil, = Minist=E9rio=20 da Sa=FAde. PNIIS =96 Pol=EDtica Nacional de Informa=E7=E3o e = Inform=E1tica em Sa=FAde;=20 proposta vers=E3o 2.0; inclui delibera=E7=F5es da 12a=20 Conferencia Nacional de Sa=FAde. Bras=EDlia: MS, 2004. Available at:=20 www.datasus.gov.br.

20. Brasil, = Minist=E9rio=20 da Sa=FAde. Portaria n=B0 35 de 4 de janeiro de 2007 que institui, no = =E2mbito do=20 Minist=E9rio da Sa=FAde, o Programa Nacional de Telessa=FAde. = Bras=EDlia: MS, 2007.=20 Available at:=20 dtr2004.saude.gov.br/dab/docs/legislacao/portaria35_04_01_07.pdf.

21. Barbosa = AK, de A=20 Novaes M, de Vasconcelos AM. A web application to support telemedicine = services=20 in Brazil. AMIA Annu Symp Proc 2003: 56=9660.

22. Tomasi E, = Facchini=20 LA, Osorio A, Fassa AG. Aplicativo para sistematizar informa=E7=F5es no = planejamento=20 de a=E7=F5es de sa=FAde p=FAblica. [Software program to systematize data = for planning=20 public health actions.] Rev Sa=FAde Publica 2003; = 37:=20 800=966.

23. MS = (Minist=E9rio da=20 Sa=FAde). DATASUS: informa=E7=F5es em sa=FAde Bras=EDlia: MS, 2002. = Available at:=20 www.datasus.gov.br.

24. OMS = (Organiza=E7=E3o=20 Mundial da Sa=FAde). CID 10. [International Classification = of=20 Diseases, 10th revision.] S=E3o Paulo: EDUSP, 1996.

5 Community-based health workers in developing = countries=20 and the role of m-health

Adesina Iluyemi

Introduction

The World Health Organization (WHO) has proposed the = use of=20 low-cost information and communication technology (ICT) to improve the = quality=20 of service delivery and to build up health workers=92 capacity = especially at the=20 primary health care (PHC) level.1 This=20 application of ICT in health care has been termed e-health.2 = Mobile=20 e-health, or m-health, involves using wireless technologies such as = Bluetooth,=20 GSM/GPRS/3G, WiFi, WiMAX, on to transmit e-health data and facilitate = services.=20 Usually, these are accessed by the health worker through devices such as = mobile=20 phones, Smartphones, personal digital assistants (PDAs), laptops or = tablet PCs.=20 Health data stored on devices such as USB memory sticks and memory = storage cards=20 (SDs) can also be regarded as m-health tools.

The International Telecommunication Union (ITU) has = been=20 piloting m-health for health system and workers development in = developing=20 countries since 2002, especially at the PHC level.3 Most = e-health=20 development has been aimed at employing mobile/wireless ICT for PHC = service=20 development in developing countries. However, this is often not grounded = within=20 local practices in these countries. Attempts to develop new applications = without=20 taking account of local sensibilities have been known to fail.4 How = can=20 m-health be made sustainable for health workers and for PHC delivery in=20 developing countries? To answer this question, case studies on the use = of=20 m-health applications by community-based health workers (CBHWs) from = four=20 developing countries in three continents are presented in this = chapter.

Opportunities in m-health for addressing = global
health=20 problems

Health systems in developing countries face the = double burden=20 of chronic and infectious diseases. Scarce financial resources, coupled = with the=20 brain drain, have led to the loss of mostly high- and medium-level = health=20 workers. The Millennium Development Goals (MDGs) set = out by=20 the United Nations in 2000 provide targets for tackling the disease = burdens in=20 developing countries.5 The=20 health-related MDGs are to:

reduce = child=20 mortality from childhood diseases

improve = maternal=20 health

combat = HIV/AIDS,=20 tuberculosis and malaria.

These diseases have affected the fabric of society. = Timely=20 achievements of the health-related goals of MDGs in developing countries = according to WHO can be attained by adopting the principles of the Alma = Ata=20 Declaration on Primary Health Care.6 This = implies=20 that the PHC service model could be the best approach to the management = of the=20 health-related MDGs in developing countries. However, the shortage of = human=20 resources is a major impediment to achieving the MDGs. Recently, there = have been=20 calls to focus strategies on the development of =91substitute health = workers=92 for=20 providing health services in developing countries.7,8 CBHWs = are=20 long-standing providers of primary health care in many developing = countries, and=20 can be considered as =91substitute health workers=92 in this = context.

These factors all provide a rationale for introducing = m-health=20 for CBHWs and making policy changes to produce health system reforms in=20 developing countries.

Primary health care

PHC is operationalized through the district health = system=20 (DHS). The DHS is a hierarchical organizational structure for PHC = service=20 delivery, and is made up of four or five integrated levels of health = service=20 delivery configuration. PHC forms the first level of contact of = individuals, the=20 family and community with the national health system. Essential health = services=20 are provided through the PHC system using community outreach programmes = and=20 facilities. CBHWs are regarded as the lowest cadre within the PHC = system.

CBHWs are a variety of health workers who are = selected, trained=20 and work within communities. They normally have a shorter education than = professional workers. In developing countries, they are usually located = in rural=20 and semi-urban settings, but may also operate in urban areas. CBHWs are = either=20 paid staff or volunteers, and are trained within the local community in = which=20 they are expected to operate. They also perform specialist functions = such as=20 providing reproductive health and family planning, nutrition education, = and=20 community rehabilitation for convalescing and disabled patients. As well = as=20 delivering essential health services, CBHWs are also agents for health = promotion=20 in the community in which they live and work. They also act as advocates = for=20 socioeconomic development and community empowerment.

Five case studies that illustrate aspects of = implementing=20 m-health innovations with CBHWs in developing countries are presented=20 below.

Case study 1

Background

The Ca:sh (Community Access to Sustainable = Health)=20 programme was instituted in India in 2001. Large quantities of = health data=20 are generated by the PHC system in India. This is used for = treatment=20 planning, resource allocation, disease surveillance and = management. Moving=20 this information from the lower level to the district level of the = PHC=20 system in a timely and accurate manner was difficult because of = the size=20 of India=92s health system. The Ca:sh programme was conceived to = provide a=20 cost-effective method of managing and accessing these large = volumes of=20 health data. The CBHWs (usually auxiliary nurses or midwives) = provide=20 community, maternal and childhood care. The m-health application = was=20 developed to support the CBHWs in rural communities where most of = the=20 population live.

Case description

The m-health application was piloted in 2001 in = a rural=20 community with a population of 70 000. The Ca:sh programme was = implemented=20 by local staff in conjunction with the international developers. = There was=20 a two-stage implementation process involving a participatory = approach in=20 order to engage with the CBHWs. The first stage lasted for five = months,=20 and problems that were identified were incorporated into the = design=20 process. The second stage lasted for nine months, and culminated = in a=20 programme evaluation exercise. During this process, technical = support and=20 training for the CBHWs were provided by the local implementers. = The=20 training for the CBHWs also followed the two phases of the design=20 process.

The m-health application enables the CBHWs to = collect=20 household, demographic, antenatal and prenatal, and childhood = immunization=20 data at the point of care in the patients=92 homes. The data = collected by=20 the CBHWs are then transferred at regular intervals to a central=20 repository located at a district health centre. Unfortunately, = despite a=20 successful demonstration phase, the project was discontinued owing = to lack=20 of support by the national government.9

Case study 2

Background

The Hispano-American Health Link (EHAS) = programme was=20 instituted in Peru in early 2000. Maternal and childhood diseases = such as=20 respiratory and gastrointestinal infections are common in Peru, = especially=20 in rural areas. Rural villages have health posts that are usually = staffed=20 by CBHWs, who provide PHC services. Usually, CBHWs depend on the = bigger=20 health centres for second opinions, case referrals, pharmaceutical = deliveries and service administration. However, the execution of = these=20 activities was very difficult because of poor communications. = Often, the=20 CBHWs spent hours or even days travelling to the health posts. The = EHAS=20 m-health system was designed to tackle this problem.

Case description

The EHAS programme commenced with a pilot = project=20 involving the deployment of 39 sets of m-health equipment to the = health=20 posts and centres within a district health system. This was = preceded by a=20 comprehensive assessment of the ICT needs of CBHWs in the region. = This=20 indicated that lack of communication facilities hampered the = coordination=20 of the CBHWs=92 activities, sharing and exchange of information, = and their=20 education. The contents of the m-health application included = e-learning=20 materials such as journals, evidence-based guidelines and local = health=20 news, mostly for managing childhood and maternal health care. An online e-learning test and assessment system = was also=20 provided. Access to experts=92 or second opinions was also = provided through=20 a store-and-forward teleconsultation system.

The implementation involved the participation = of local=20 authorities and host communities in the development and = installation of=20 the m-health equipment. Training was provided for the local = implementers,=20 who in turn trained the CBHWs. The training included material on = computer=20 literacy, the operation of the m-health communication system and = simple=20 maintenance procedures. Two local technicians from the district = hospital=20 were trained in equipment maintenance and repair procedures. In = addition,=20 training was also provided for the managers at the district = hospital on=20 how to configure the m-health application to their local=20 requirements.

At the completion of the nine-month pilot = implementation,=20 an evaluation was carried out to measure the impact of m-health on = the=20 community, on the CBHWs and on health service delivery. This was = compared=20 with the baseline study conducted at the start of the project. = Findings=20 from the evaluation were then employed to further improve and = develop the=20 m-health application. In the last seven years, the programme has = provided=20 valuable lessons on using high-bandwidth wireless ICT for rural = m-health.=20 Similar programmes in Columbia and Cuba have been inspired by this = success.10,11

<= /TD>

Case study 3

Background

Cell-Life is a project in South Africa focusing = on the=20 management of the HIV/AIDS epidemic. South Africa has one of the = highest=20 rates of HIV/AIDS rate in the world. In 2004, there were = approximately 3.8=20 million people infected with the HIV/AIDS virus. In response, the = South=20 African government commenced a nationwide programme of = antiretroviral=20 (ARV) therapy for people living with HIV/AIDS (PLWHA). PLWHA are = usually=20 managed by state and community-based organizations. However, these = often=20 lack resources. Most PLWHA are resident in rural areas where there = is a=20 lack of basic amenities, and often the supply of ARV drugs to = these=20 centres is unreliable, thereby predisposing these patients to = secondary=20 infections such as tuberculosis. The South African government also = recognized the importance of up-to-date information and access to=20 communication facilities for the support and empowerment of=20 PLWHA.

Case description

Initially, Cell-Life started as a community = home-based=20 care system for the direct management of HIV/AIDS patients known = as=20 =91Aftercare=92. However, it has since been expanded to cover = other aspects of=20 the HIV/AIDS management process, such as pharmacy stock control, = voluntary=20 counselling and testing. The Aftercare module was designed for = volunteer=20 CBHWs known as therapeutic counsellors for the management of = PLWHA.=20 Therapeutic counsellors are PLWHA who are also undergoing ARV = therapy=20 themselves, but are more in control of their health situation. = This=20 represents a kind of peer-to-peer homecare management model. Each = CBHW is=20 usually allocated to 15=9620 PLHWA. This involves the CBHWs = providing care=20 and support to their fellow PLHWA in their homes, and ensuring = their=20 compliance with ART treatment regimens. The m-health system = supports these=20 CBHWs in their health volunteer activities.

The first pilot was implemented in 2002 at a = rural HIV=20 research centre. Training and continuous supervision were provided = by a=20 doctor from the local university hospital. The mobile devices were = provided for the CBHWs by the clinic for their professional and = personal=20 use. The clinic is also responsible for maintenance of the mobile=20 devices.

Basically, the m-health innovation is used by = the CBHWs=20 for accessing real-time health and ART records of their fellow = PLHWA=20 during home visits. Information collected includes drug=20 dosage and side effects, and relevant socioeconomic indicators. = This=20 information is transmitted via a public wireless network to a = central=20 database for analysis by a care manager; feedback is then provided = for the=20 CBHWs as required. Real-time communication between the care = manager and=20 CBHWs is usually by voice communication. The care manager also = employs the=20 data for monitoring the CBHWs=92 activities.

In 2002, there were 6 CBHWs and 250 patients. = At present,=20 there are about 46 CBHWs in 4 rural and peri-urban sites, managing = about=20 3500 PLWHA. Recent indications are that the programme may not be = sustained=20 because of financial constraints.

Case study 4

Background

In India, traditional health practices serve as = alternatives to formal health services, and meet the health needs = of the=20 mostly rural and poor population. Ayurveda, a 5000-year-old = practice, is=20 an example. Ayurveda uses medicinal plants to create low-cost = drugs for=20 managing chronic and acute diseases. These services are delivered = by=20 traditional CBHWs, who provide home consultation to clients in = rural=20 areas. In 2001, Jiva Health, an Ayurvedic health care provider, = decided to=20 develop an m-health system known as Jiva TeleDoc for supporting = the=20 homecare activities of its CBHWs. The aim was to develop a = sustainable=20 solution that was appropriate for the primary health needs of = villagers in=20 India.

Case description

The aim of the Teledoc innovation was to = identify health=20 care priorities. The design and development were carried out in = India. The=20 first pilot was a feasibility assessment study that lasted for a = month in=20 a selected village. This was to determine the contextual = sustainability=20 factors for the m-health innovation within the village = environment. After=20 a successful pilot study, the m-health programme was then extended = to=20 another 15 villages, where further piloting was conducted for = another=20 three months.

The m-health application enables CBHWs to = update and view=20 medical records in their clients=92 homes, away from the health = centre. A=20 store-and-forward teleconsultation can be carried out by the CBHWs = with=20 the urban health centre. At the urban health centres, an Ayuverdic = doctor=20 interprets the received data and then prescribes drugs, which are = then=20 delivered to the clients by CBHWs. In the pilot trial, CBHWs = conducted 800=20 home visits with the m-health application. The project was then = extended=20 to another 30 villages in 2003. By 2006, the m-health application = had been=20 employed for the management of nine million homecare visits in = about 10=20 000 villages.12 The = CHITS programme in the Philippines13 = (see=20 also Chapter = 3)=20 also began as an m-health project.

Case study 5

Background

In Uganda, the Ministry of Health recognized = that the=20 ability to collect and analyze reliable information was vital for=20 providing effective health care to the population. Therefore, a = functional=20 health management information system was required. An = international=20 coalition led by a university-based organization developed the = Uganda=20 Health Information Network (UHIN), an m-health application. The = network=20 used low-cost mobile ICT in a computerized health management = information=20 system and also provided access to e-health learning materials for = all=20 health workers, including CBHWs.

Case description

The m-health work started as a pilot project in = two=20 health districts in Uganda in 2003. Pre-implementation planning = was=20 carried out through awareness-raising workshops at the pilot = sites.=20 Experience from previous m-health projects involving mobile = devices=20 without wireless connectivity in other parts of Africa also = provided=20 insights. The implementation was carried out by Ugandan workers = from local=20 and national health organizations and coordinated by a = university-based=20 research and development institution. The information content was=20 developed through a participatory approach with the local health = workers=20 who were going to be the eventual users. This process involved the = digitization of the existing paper-based health data forms, = decision=20 support guidelines and educational materials.

Technical support and training were provided = continuously=20 throughout the early phase of the implementation process. = Basically, the=20 innovation consisted of two main applications, namely the health=20 management information system and the e-learning contents. The = e-learning=20 contents included locally developed and WHO guidelines for = managing=20 health-related MDGs.

In 2003, 200 PDAs were distributed to 386 = health workers=20 in two health districts. By 2006, 350 mobile devices were in use. = A large=20 proportion of these health workers were CBHWs. As there were too = few=20 mobile devices to go round, up to six CBHWs in health posts or = centres=20 were observed to be sharing one device for their daily PHC=20 activities.14

<= /TD>

Case study summary

The development and implementation of the m-health=20 applications in the above case studies involved mostly international and = not-for-profit academic and research organiz ations working with local=20 collaborators. These are listed in Table = 5.1.

Table 5.1 Stakeholders = involved in=20 m-health project development and implementation
	International = implementers	Local = implementers
Ca:sh 1.	Dimagi USA	1. Media Lab India
	2. Massachusetts Massachussets Institute of = Technology=20 (MIT), USA	2. All India Institute of Medical Sciences = (AIIMS),=20 India
		3. State Ministry of Health of Haryana, = India
EHAS	1. Biomedical Engineering and Telemedicine = Group of the=20 Technical University of Madrid (GBT=96UPM), Spain	1. Catholic University of Peru = (PUCP)
		2. Cayetano Heredia University of Peru = (UPCH)
	2. Engineering Without Frontiers (ISF), = Spain
		3. Ministry of Health of Peru = (MINSA)
Cell-Life	None	1. Cell-Life
		2. University of Cape Town (UCF), South = Africa
		3. Cape Peninsular University of Technology, = South=20 Africa
		4. Desmond Tutu Institute
Jiva TeleDoc	1. Media Lab MIT	1. Jiva Health, Jiva Institute, = India
		2. Media Lab India
		3. Indian Institute of Technology
UHIN	1. AED/Satellife	1. Uganda Chartered HealthNet (UCH), = Uganda
		2. Makerere University Medical School, = Uganda
		3. District Health Authorities,=20 Uganda

Table 5.2 M-health = technology
Case	Technology
Ca:sh	1. PDAs
	2. Compact storage card (SD)
EHAS	1. VHF wireless networks and = transceivers
	2. WiFi wireless networks and = transceivers
	3. WiFi cards and routers
	4. Laptops
	5. Solar panels
	6. Email
Cell-Life	1. Smartphones and mobile phones
	2. SIM cards
	3. SMS/GSM/GPRS/3G
	4. Mobile web
Jiva TeleDoc	1. Smartphones
	2. GSM/GPRS
	3. Mobile web
UHIN	1. PDAs
	2. Portable wireless servers
	3. GSM/GPRS
	4. Solar panels
	5. Mobile email

Table 5.3 M-health project = funding=20 sources
Case	Funding = organizations
Ca:sh	1. Media Lab India
	2. Ministry of Information Technology, = Government of=20 India
	3. Fogarty International Centre, National = Institutes of=20 Health (NIH), USA
	4. Media Lab, Massachusetts Institute of = Technology,=20 USA
EHAS	1. Spanish Agency for International Cooperation = (AECI)
	2. Spanish Interministerial Commission for = Science and=20 Technology (CICYT)
	3. Latin American Program for Science and = Technology for=20 Development (CYTED)
	4. Supervisory Organization for Private = Investments in=20 Telecommunication in Peru (OSIPTEL)
	5. World Bank InfoDev program
	6. Committee for Solidarity and Development of = the UPM,=20 the Council of Madrid
	7. Spanish Association of Engineers of the ICAI = and the=20 Official Association of Industrial Engineers of Spain = (COIIM)
Cell-Life	1. Vodacom Foundation
	2. National Research Foundation of South = Africa
UHIN	1. Connectivity Africa: International = Development=20 Research Centre (IDRC), Canada
Jiva TeleDoc	1. George Soros Foundation
	2. Flora Family Foundation
	3. Media Lab = Asia

Different low-cost technologies were employed in the = m-health=20 work described in the case studies (Table 5.2). = The source=20 of funding for these m-health programmes was mostly international = not-for-profit=20 organizations (Table=20 5.3).

The effects of the m-health projects can be considered = under=20 four headings: technology interfaces, social, finance, and = government.

Technology interfaces

The m-health projects described above were generally = employed=20 to extend essential PHC services to mostly rural communities previously = without=20 services. Different types of CBHWs were involved. For example, in the = Ca:sh=20 project, they performed specialist functions in maternal and = childcare.

The importance of engaging users in the development = process was=20 a common factor in most of the cases. The participatory design = approach15,16 = adopted in=20 the Ca:sh17 and = EHAS18 = projects=20 should be more widely employed, even though it did not result in = sustainability=20 for the Ca:sh project. Participatory action research19 was = employed=20 in the design and implementation process of the TeleDoc and EHAS = projects. Here,=20 community members, the users of the m-health services, were engaged in = the=20 development work. An iterative design approach was employed in all the = projects,=20 but most notably in the Ca:sh17 and = EHAS20 = projects.

User interface design was also important. The users = were=20 involved in the mobile devices interface design process, especially in = the Ca:sh=20 project. Of particular importance is engaging users in the adaptation = process of=20 fitting paper-based content to device screens. User engagement in = interface=20 design has a role to play in successful mobile device usability and = eventual=20 adoption.15 = However, this=20 cannot be carried out in isolation. In a failed innovation, CBHWs = abandoned=20 their devices, despite an intensive long-term action, research-oriented = design=20 process, because other contextual factors were not appropriated into the = planning process.21

The prior exposure of the CBHWs to mobile devices in = the=20 Cell-Life project and their exposure to desktop computers in the Ca:sh = project=20 were reported as being important to rapid adoption. Another factor was = the=20 training provided to the CBHWs. Training for users has been identified = as=20 important to the successful adoption of e-health in developing = countries.22 In = the=20 Cell-Life project, there was an increased health care workload on the=20 CBHWs.23 = However, the=20 health care competence of the CBHWs was observed to be enhanced by = m-health in=20 both the Cell-Life and UHIN projects.14,23

Social

Personal security concerns may be a barrier to the = adoption of=20 m-health. In the Cell-Life project, some CBHWs were observed to leave = their=20 mobile devices at home because of fear of armed robbery while working in = the=20 community.23 = There were=20 also social effects of m-health on the work of the CBHWs. Some CBHWs = complained=20 about intrusion into their private lives in the Cell-Life project.23 = This=20 perceived intrusion was identified as a limiting factor in the adoption = of=20 m-health.

A positive social effect observed in the Cell-Life = project was=20 that the CBHWs=92 status within their working and professional community = was=20 enhanced by the m-health work.23 = Another=20 social effect, albeit a negative one, was observed in the UHIN project = as an=20 outcome of the CBHWs=92 team-working. As a consequence of the shortage = of mobile=20 devices, the CBHWs had to share them.14 = Sharing a=20 mobile device is common in many developing countries.24 = This should=20 not, however, be the case with CBHWs, because of their health care role. = Each=20 health worker deserves to have a personal device in order to manage and = secure=20 their patients=92 data, access email and use the device at any time for=20 educational purposes.

Finance

Sustaining m-health projects in developing countries = should be=20 important to health policy makers. Most of the cases described above = started as=20 pilots, and most have since been expanded beyond their sites of origin. = Thus,=20 valuable lessons can be gained from their experiences.

The funding sources for these m-health projects are = summarized=20 in Table = 5.3. Most=20 were funded from outside the countries of implementation, with the = exception of=20 Cell-Life and Jiva TeleDoc. Most of the financiers were non-governmental = organizations. It is known that developing countries are replete with = abandoned=20 health projects caused by the short-term focus of international=20 implementers.4,25 = This=20 observation is also supported by empirical work on the sustainability of = PHC=20 innovations in developing countries.26 = Sustainable=20 PHC innovations were dependent on the degree of integration of local and = contextual organizational factors in their planning. Financial = sustainability of=20 PHC innovations was observed to be important to local stakeholders.27

The financial basis of some of these cases is = therefore worth=20 considering. For instance, both the Jiva TeleDoc and Cell-Life = innovations were=20 run as social enterprises. Social enterprises are organizations that = develop new=20 solutions to social problems.28 = They can be=20 run as a business or as a not-for-profit operation. However, the common = goal is=20 to ensure financial sustainability while solving societal issues. They = are also=20 known to provide an alternative to inefficient public services.28 The = m-health=20 projects were social enterprises that filled the gap created by = underperforming=20 public health services. In future, perhaps, health policy makers should = adopt=20 this approach to meet the health-related MDGs of developing = countries.

However, taking the social enterprise approach is not = without=20 its own problems.29 = Both the=20 TeleDoc and Cell-Life applications were developed with seed funding from = their=20 sponsors, but achieving financial sustainability was difficult. The = Cell-Life=20 m-health work started as a donor-funded research project in response to=20 government policy on HIV/AIDs care.30 = However, it=20 has since mutated to an =91academic research-based=92 social = enterprise.

Other m-health applications have also struggled to = achieve=20 financial sustainability. In the case of the now defunct Ca:sh = innovation,=20 long-term sustainability could not be attained owing to withdrawal of = funding by=20 its main sponsor, the Indian government.9 Indeed, the long-term viability of private funding for = m-health=20 innovations in developing countries has been questioned. In an analysis = of the=20 financial constraints encountered in scaling up the TeleDoc application, = Singh31 = argued for=20 complementary government funding.

Government

Despite some impressive results in the UHIN project, = including=20 scaling up from two to five health districts,14=20 institutionalization into the national health system has not yet been = achieved.=20 The UHIN project started as a commitment made by government leaders on = MDGs at=20 the G8 meeting in 2002. It was funded initially by the Canadian = government.=20 Substantial buy-in has been achieved with governments at the district = level.=20 However, this has not occurred at the national government level. This = may=20 jeopardize its future financial security.32

Despite these financial concerns, the UHIN project = managed to=20 attain international visibility. It has been transferred to neighbouring = Mozambique and planning is under way in Rwanda. Information from the = Mozambique=20 project indicates that early involvement of the government has = contributed=20 immensely to its diffusion.32

From the above, it can therefore be surmised that = direct or=20 indirect government support affects the financial sustainability of = m-health=20 applications in developing countries. Governments at local/district, = national=20 and even international levels have a significant role to play.

International governmental and non-governmental = financial=20 support is also important. Funding from the Spanish government enabled = the=20 implementation of the EHAS project. Non-governmental international = financiers=20 may, however, have a different outlook. Engineering professionals,=20 telecommunication companies and international development organizations = all=20 contributed to the EHAS project.

Conclusion

Frequent misalignment between international = development=20 strategies and local realities in developing countries has been observed = as a=20 major cause of failure of initiatives and of wasted resources.4 There = has often=20 been a lack of coherence between micro-level practices and strategic or=20 macro-level policies.33 The = outcomes=20 of the m-health case studies are the results of micro-level practices = within the=20 health systems of developing countries. National and international = policy=20 initiatives, especially within the sphere of global health, are typical = of=20 macro-level practices. National and international grants, and social=20 philanthropy, are important for sustainable m-health. So is = institutional=20 support from both national and international organizations. = Institutional and=20 financial support from national and district governments is required for = long-term, successful m-health.

References

1.=20 World Health Organization. WHA58.28 e-health. Geneva: WHO, = 2005.

2.=20 World Health Organization. Strategy 2004=962007. E-health for Health = Care=20 Delivery. Geneva:, WHO, 2004

3.=20 Tomioka Y, Androuchko V, Nakajima I et al. An aspect of the ITU-D = activities=20 from a viewpoint of ehealth and human resource development. In: = Proceedings=20 of 8th International Conference on e-Health Networking, Applications and = Services, 2006: 283=966.

4.=20 Heeks R. Information systems and developing countries: failure, success, = and=20 local improvisations. Inf Soc 2002; 18: = 101=9612.

5.=20 United Nations. Millennium Development Goals. Available at:=20 www.un.org/millenniumgoals/.

6.=20 Kekki P. Primary health care and the Millennium Development Goals: = issues=20 for discussion. Geneva: WHO, 2004.

7.=20 Dovlo D. Using mid-level cadres as substitutes for internationally = mobile health=20 professionals in Africa. A desk review. Hum Resour Health 2004; = 2: 7.

8.=20 Hongoro C, McPake B. How to bridge the gap in human resources for = health.=20 Lancet 2004; 364: 1451=966.

9.=20 Keim B. Vikram Kumar. Nat Med 2007; 13: = 113.

10. = Mart=EDnez A,=20 Villarroel V, Puig-Junoy J et al. An economic analysis of the EHAS = telemedicine=20 system in Alto Amazonas. J Telemed Telecare 2007; = 13:=20 7=9614

11. = Mart=EDnez A, L=F3pez=20 DM, S=E1ez A et al. Improving epidemiologic surveillance and health = promoter=20 training in rural Latin America through information and communication=20 technologies. Telemed J E Health 2005; 11:=20 468=9676.

12. = Bhattacharyya A.=20 Distance Doc. GPs with GPRS. BusinessToday India 2004; = 1128=9630.

13. Tolentino = H,=20 Marcelo A, Marcelo P, Maramba I. Linking primary care information = systems and=20 public health information networks: lessons from the Philippines. = Stud=20 Health Technol Inform 2005; 116: 955=9660.

14. = SatelLife.=20 Uganda Health Information Network Phase II. Ottawa: IDRC, = 2006.

15. Graves M, = Grisedale=20 S, Gr=FCnsteidl A. Unfamiliar ground: designing technology to support = rural=20 health-care workers in India. ACM SIGCHI Bull 1998;=20 30: 134=9643.

16. Graves M, = Reddy NK.=20 Electronic support for rural health-care workers. In: Bhatnagar S, = Schware R,=20 eds. Information and Communication Technology in Development: Cases = from=20 India. New Delhi: Sage Publications, 2000: 35=9649.

17. = Anantraman V,=20 Mikkelsen T, Khilnani R et al. Handheld computers for rural healthcare,=20 experiences in a large scale implementation. In: Proceedings of the = 2nd=20 Development by Design Workshop (DYD02), 2002.

18. = Mart=EDnez A,=20 Villarroel V, Seoane J, del Pozo F. Analysis of information and = communication=20 needs in rural primary health care in developing countries. IEEE = Trans Inf=20 Technol Biomed 2005; 9: 66=9672.

19. Byrne E, = Gregory J.=20 Co-constructing local meanings for child health indicators in = community-based=20 information systems: the UThukela District Child Survival Project in=20 KwaZulu=96Natal. Int J Med Inform 2007; = 76(Suppl 1):=20 78=9688.

20. Martinez = A,=20 Villarroel V, Seoane J, Pozo FD. Rural telemedicine for primary = healthcare in=20 developing countries. IEEE Technol Soc Mag 2004; = 23:=20 13=9622.

21. Ranjini = CR, Sahay=20 S. Computer-based health information systems =96 projects for = computerization or=20 health management? Empirical experience from India. In: Tan J, ed. = Medical=20 Informatics: Concepts, Methodologies, Tools, and Applications. = Hershey:=20 Medical Information Science Reference, 2008.

22. Kimaro = HC.=20 Strategies for developing human resource capacity to support = sustainability of=20 ICT based health information systems: a case study from Tanzania. = Electron J=20 Inf Syst Dev Countries 2006; 26: 1=9623.

23. Skinner = D, Rivette=20 U, Bloomberg C. Evaluation of use of cellphones to aid compliance with = drug=20 therapy for HIV patients. AIDS Care 2007; 19:=20 605=967.

24. Donner J. = The use=20 of mobile phones by microentrepreneurs in Kigali, Rwanda: changes to = social and=20 business networks. Inf Technol Int Dev 2007; = 3:=20 3=9619.

25. Heeks R, = Mundy D,=20 Salazar A. Why Health Care Information Systems Succeed or Fail. = Manchester: Institute for Development Policy and Management, 1999.

26. Sarriot = EG, Winch=20 PJ, Ryan LJ et al. Qualitative research to make practical sense of=20 sustainability in primary health care projects implemented by = non-governmental=20 organizations. Int J Health Plann Manage 2004; = 19:=20 3=9622.

27. Sarriot = EG, Winch=20 PJ, Ryan LJ et al. A methodological approach and framework for = sustainability=20 assessment in NGO-implemented primary health care programs. Int J = Health=20 Plann Manage 2004; 19: 23=9641.

28. Harding = R. Social=20 enterprise: the new economic engine? Business Strategy Review = 2004;=20 15: 39=9643.

29. Dees JG, = Elias J.=20 The challenges of combining social and commercial enterprise. = Business=20 Ethics Quarterly 1998; 8: 165=9678.

30. Wessels = X.=20 Improving the efficiency of monitoring adherence to antiretroviral = therapy at=20 primary health care level: a case study of the introduction of = electronic=20 technologies in Guguletu, South Africa. Development Southern = Africa=20 2007; 24: 607=9621.

31. Singh N. = ICTs=20 and Rural Development in India. Available at:=20 ssrn.com/abstract=3D950322.

32. Batchelor = S.=20 Connectivity Africa External Review Report. Ottawa: IDRC, = 2007.

33. Madon S, = Sahay S,=20 Sudan R. E-government policy and health information systems = implementation in=20 Andhra Pradesh, India: need for articulation of linkages between the = macro and=20 the micro. Inf Soc 2007; 23: 327=9644.

6 Global e-health policy: From concept to=20 strategy

Richard E Scott

Introduction

It is likely that all aspects of health or health = care will be=20 affected by e-health, the broad use of information and communications = technology=20 (ICT) in the health sector. No individual, organization, business or = government=20 can therefore afford to ignore this development.

The concept of global health has emerged in the past = decade.=20 Given that the capabilities of e-health and the health needs of the = global and=20 local population are complementary, worldwide provision of the benefits = of=20 e-health, i.e. =91global e-health=92, is also an appropriate concept. = But, to=20 accomplish this, e-health must be integrated into domestic and global = health=20 care systems at both practical and policy levels. The focus to date has = been on=20 addressing matters related to the practical implementation of e-health = in the=20 local or domestic context, which is proving difficult enough. With rare=20 exceptions, attention to the issues of integration and broader e-health = policy=20 development has been fragmented or non-existent.

The rapid development of e-health is causing many = changes, the=20 social outcomes of which will be mixed. Winners will be best placed to = take=20 advantage of the changes. Losers will not only be left behind = technologically,=20 but also be in danger of losing the expanded services capable of being = provided=20 through e-health. In order to maximize the number of winners, many = challenges=20 must be addressed. Principal among these is a global e-health = policy.

Need for a global policy

Does a need exist for a global e-health policy? = Consider the=20 following =91North=96South=92 scenario.

A 55-year-old man has recently returned home to a = remote=20 northern community in a Canadian province after a six-week trip to = Tanzania and=20 South Africa, during which he travelled and camped extensively in the = bush. Upon=20 his return, he has fallen severely ill and is bedridden with an unknown = disease,=20 exhibiting fever, extreme debilitating pain in joints and muscles, and a = skin=20 eruption. The patient=92s doctor has identified a specialist in rare = tropical=20 diseases who works at the Nelson Mandela School of Medicine in Durban, = South=20 Africa. An urgent video consultation is desired for = diagnosis=20 and treatment, and for guidance for local management. Can we do this? = Both=20 locations have access to video-consultation units, good experience with = local=20 use of this equipment and adequate bandwidth. From a technical = perspective,=20 therefore, we can do it.

Both clinicians are agreeable and local chief = information=20 officers are approached to arrange the logistics of the consultation. = Having=20 been alerted, senior administrators in the relevant health region in = Canada ask=20 questions. Who is this specialist in Durban, and what training or = certification=20 does she have? Is her expertise recognized in Canada? Is this within her = scope=20 of practice? Will she expect remuneration? Will this open the flood gate = to many=20 similar requests? Since diagnosis and treatment are needed, will she be=20 considered to be practising in Canada? What are the licensing issues? = Who will=20 have clinical accountability? What about liability to the hospital and = health=20 region? Will there be any ethical, confidentiality or privacy = complications? For=20 clinical continuity and appropriate care, will the consultant need to = review the=20 patient=92s electronic health record, or need to enter her opinion in = the record=20 after remote patient examination? If so, what about security, and how = will=20 access and authorization be achieved since she is not an employee and = does not=20 currently have approval? Is any diagnostic equipment licensed and = approved for=20 use =96 and where? How much does this matter?

The health region=92s risk manager advises against the = teleconsultation, and the Provincial Privacy Commissioner says that he = will=20 examine the issue and provide a response =96 probably next month. The = outcome is=20 confusion and uncertainty about what to do or how to do it, since there = is=20 simply no clear local, subnational, national or even global policy or=20 legislation to show the way. As an alternative, a specialist in another = Canadian=20 province is contacted. But, now sensitized, the administration raises = the same=20 issues. The videoconference is cancelled =91due to technical = difficulties=92.

And the patient =85 ?

Global health

Global health has been defined as those =91health = problems,=20 issues and concerns that transcend national boundaries, may be = influenced by=20 circumstances or experiences in other countries, and are best addressed = by=20 cooperative actions and solutions=92.1 Global health, similar to its = predecessor,=20 international health, maintains a strong focus on the prevention and = treatment=20 of infectious diseases such as HIV, malaria and tuberculosis. In = addition,=20 however, global health is focused on the identification and eradication = of=20 underlying conditions that contribute to the persistence of disease. = These=20 include disparities in access to care, cultural and psychosocial factors = that=20 impede the prevention and treatment of disease, and issues of extreme = poverty,=20 violence and war.1 The use of e-health, i.e. global = e-health, could=20 influence each of these areas.

In most countries, major policy matters include the = need for=20 increased access to health care services and health reduction in = inequity.=20 Complicating factors include the ageing population, the shortage and=20 maldistribution of health care providers, the growth of chronic disease = and poor=20 literacy. Many tools will be needed to address these health care = problems, among=20 which must be global e-health.

Global e-health

The term =91global e-health=92 appears to have been = used from=20 about 2000. The relationship of its components is shown in Figure 6.1. = With=20 recognition of its potential to have a profound effect on the health of = the=20 world=92s population, it has taken on new meaning and new = significance.

A variety of definitions of telemedicine, telehealth = and=20 e-health have arisen over time, leading to some confusion and semantic = debate.=20 Common to all are the elements of the use of ICT, distance between = participants,=20 and health or medical application. Not typically included have been = aspects of=20 global application, crossing of existing boundaries and integration into = current=20 health care practice. Considering these perspectives, a definition was = proffered=20 in 2003 that was consistent with the accepted goals and terms used by = the World=20 Health Organization (WHO). Thus global e-health is:2

The sustainable global integration of information = and=20 communications technologies into the practice of protecting and = promoting health=20 across geo-political, temporal, social, and cultural barriers =96 = including=20 research and education =96 to facilitate health, public and community = health,=20 health systems development and epidemiology.

Global e-health recognizes the interdependence of = all nations=20 and the mutual benefit of a flow of health information, knowledge and = resources=20 between countries.

Relevance of global e-health

MacPherson and Gushulak3 identified the breakdown of traditional = public=20 health barriers to transmissible virulent diseases that has been caused = by=20 modern modes of

3DImage=20

Figure 6.1 The relationship of the = major=20 components of e-health (telemedicine and health informatics) to global = e-health.=20 Also shown are subcategories of both major components, some examples of=20 applications [square brackets], plus distinct but related elements = (e-commerce=20 and e-learning).

transportation. A potentially contagious person or = product can=20 now travel to anywhere in the world within 1=962 days. Kaul and Faust4 noted the relevance of this in terms of = political=20 boundaries =96 =91In today=92s world, globalization has brought about=20 interdependencies that blur the distinction between domestic and = external=20 affairs=92 =96 and noted that =91the best way to ensure one=92s own = well-being is to be=20 concerned about that of others=92.

Given these perspectives, it is important to recognize = the=20 potential for global e-health to affect the health and health care of = the=20 world=92s population. There are many potential benefits:

= System =96=20 improved administration, communication and surveillance capabilities; = better=20 patient self-management; lower health system costs.

= Provider =96=20 improved distance education and remote skill development; networks for = rural or=20 isolated professionals.

= Patient =96=20 improved education and disease management; reduced patient costs = (reduced=20 travel, less time off work, decreased waiting time); positive influence = on=20 health outcomes.

= Public =96=20 improved education to maximize independent living and quality of = life.

Such benefits have already been demonstrated in many = industrialized countries, but usually in small-scale e-health = applications. The=20 opportunity exists to achieve benefits on a more widespread basis, but = several=20 factors will influence this, particularly in regard to developing = countries.=20 Some are health related, some are ICT related, and others touch on=20 socio-political matters, including cultural sensitivities, governance = and=20 policy.

Global e-health and developing = countries

It is reasonable to speculate that most of the = world=92s=20 countries have been exposed to e-health in some fashion. Developing = countries=20 perhaps have both the most to gain and the most to lose from = =91e=92applications,=20 including global e-health (Figure 6.2). = They have=20 the most to gain through providing increased access to, and greater = equity of,=20 health care to their large, under-served populations. They also have the = most to=20 lose, since significant investment in time, effort and funding will be = needed to=20 raise their health and e-health infrastructure to the required levels,=20 potentially increasing their debts and potentially diverting funding = away from=20 already stressed traditional health care delivery and support.

It will become necessary to build a sound business = case for=20 global e-health investment in developing and least developed countries, = and for=20 cogent arguments to be developed about the =91return on investment=92 = (ROI). With=20 more than 80% of the world=92s population living in developing and least = developed=20 countries, there is at least a moral argument for investment in e-health = adoption and integration. However, given that exotic diseases can now = more=20 easily appear in industrialized countries, the North stands to gain from = enhanced global e-health exchange with the South, which represents = another=20 tangible and valuable ROI. The WHO=92s recent macroeconomic study

3DImage=20

Figure 6.2 The potential impact = resulting from=20 access to =91e=92 applications, including global e-health. = Industrialized countries=20 must integrate e-health into existing (legacy) health and health = technology=20 systems, and this may be viewed as a threat to traditional delivery = models.=20 Developing countries, which lack legacy systems and can adopt new = e-health=20 applications relatively easily, have the greatest opportunities to gain = from=20 e-health. Of concern is the potential for the least developed countries = to be=20 excluded from the potential gains of e-health, because of the digital=20 divide.

identifies another ROI. That study noted that = investing in=20 health in developing countries actually has a profound economic benefit = for=20 industrialized and developing countries alike.5 The benefit for developing countries = includes a=20 fitter, healthier and more productive workforce, and decreased = fecundity; the=20 benefits for industrialized countries are =96 crudely =96 more = participants (and=20 buyers) in the global market place.

Global e-health policy perspective

Despite various international health-related = collaborations,=20 notably the WHO, health policy largely remains the sovereign domain of=20 individual countries. But, to be effective, global e-health must become = fully=20 integrated into existing national, international and global = health-related=20 structures, in both a process and a policy sense. This will only be = achieved=20 through implementing globally accepted strategies, principles and = complementary=20 policy options. Such a goal is complicated by several matters, including = existing borders and boundaries, the increasing number of stakeholders = who=20 influence health care and technology activities (particularly in = developing=20 countries), changes in governance, and the breadth and complexity of=20 e-health-related policy matters, each discussed below. Failure to = address these=20 matters will create potentially impenetrable barriers that will deny the = benefit=20 of global e-health to much of the world=92s population.

Borders and=20 boundaries

Some observers consider that national borders are = becoming=20 less meaningful.6 Certainly, they are becoming more = porous to=20 health threats as a result of international mobility.3 Global e-health has the ability =96 if = developed=20 correctly =96 to transcend existing geopolitical, sociocultural and = temporal=20 boundaries. By so doing, it could help to solve some of the health care = problems=20 facing the world=92s population. This potential also raises concerns, = such as the=20 =91jurisdictional gap=92 and fear of loss of control that must be = addressed if=20 e-health is to have the desired global benefits.7=969

Stakeholders

At one time, the WHO dominated international and = global health=20 activities. However, the world health system has grown in complexity, as = well as=20 in capacity, through an increasing number of stakeholders. These now = include=20 development banks, multilateral development agencies, development = assistance=20 agencies of industrialized countries, and non-profit private = organizations such=20 as non-governmental organizations (NGOs), big international NGOs = (BINGOs),=20 international foundations, professional bodies, health and medical = assistance=20 groups, consulting agencies, academic institutions, and finally the = private=20 sector that produces medical products, health services and ICT = components. Each=20 plays a major role in the development and dissemination of ICT and the = provision=20 of health services. Collectively, they possess much of the funding and = expertise=20 necessary for technology innovation, and are now leading global research = and=20 development.

The role of NGOs has been challenged. For many years, = they have=20 performed various service and humanitarian functions, acted as = intermediaries=20 between citizens and governments, and even tended to fill voids in = governance.=20 Now challenging their position are foundations and BINGOs, often created = by=20 private companies with access to substantial resources. For example, the = Bill=20 and Melinda Gates Foundation has assets in excess of US$36 billion. In = 2007, the=20 Foundation granted just over $2 billion for their programmes, which = included the=20 Global Health Program and the Grand Challenges in Global Health.10 Compare this with the total WHO=20 biennial budget of US$2.8 billion.11

Changing=20 =91governance=92

=91Governance=92 concerns the actions and means = adopted by a=20 society to promote collective action and deliver collective solutions in = pursuit=20 of common goals =96 how to direct, shape or regulate use of something.6 It is fairly straightforward to = transfer this=20 concept to the health and =91e=92 environments. Despite various = international=20 initiatives, =91health governance=92 (and associated health policy) has = historically=20 remained largely the sovereign domain of individual countries, and, with = the=20 increasing application of ICT and e-networks within countries, the = concept of=20 e-governance has arisen. E-governance deals with the whole spectrum of = the=20 relationships and networks within government that involve the use and=20 application of ICT. The term =91e-government=92 is sometimes used, = incorrectly, in=20 place of e-governance. The former is a narrower concept and deals with = the=20 development of specific online services to citizens, such as e-tax,=20 e-transportation and e-health. In a similar way, the advent of global = ICT=20 networks and globalization is challenging these recent concepts, and = global=20 e-health governance is emerging as a major issue. How does one control=20 activities (health related and otherwise) that = increasingly=20 reside in the hands of globally distributed entities?

A notable concern is the fundamental shift in balance = and=20 growing influence of all of these entities on local, national and global = health-related decisions and policy making. The dominance of the WHO, = national=20 governments and NGOs has been superseded by a dominance of private = sector=20 conglomerates and private foundations. Each stakeholder has its own = priorities=20 and interests. Despite seeking expert input to guide direction and = investment,=20 how adequately will the needs of small communities and countries be = served? It=20 will be crucial to ensure that local and national needs take precedence = over=20 corporate, donor or facilitator needs. But the reality is that global = e-health=20 policy development is no longer the sole purview of governments and the = WHO.=20 BINGOs and large multinational companies in the health and ICT sectors = are=20 extremely influential.

At a more practical level, the intensification of = flows of=20 people and goods are generating trans-border health risks that are = different=20 from those of previous eras. These new risks require novel approaches to = health=20 governance, and there is widespread belief that the current system of=20 =91international=92 health governance does not sufficiently address = them. E-health=20 applications might assist. As a result, the concept of =91global = e-health=20 governance=92 must become a subject of greater interest, debate and = development.=20 This perhaps represents an opportunity for the WHO to remould its own = policy,=20 reclaim its confidence and influence, and take on a central role in the = global=20 e-health governance agenda.

The breadth of policy=20 issues

E-health has been practised in some countries for = several=20 decades, and comprises health informatics and telehealth (see Figure 6.1). = E-commerce=20 and e-learning are distinct but related elements. Although originally = quite=20 localized in application, e-health solutions have became more national = (crossing=20 domestic borders) and even global (crossing national borders) =96 = referred to as=20 inter-jurisdictional e-health activity.12 Such activity is often performed on = the basis of=20 =91good Samaritan=92, intra-professional consulting, or specific and = limited=20 inter-agency agreements. However, the need for broad policy to = facilitate=20 unfettered inter-jurisdictional activity has been recognized for many=20 years.13=9615

There are several commonly identified policy problems. = For=20 health informatics, they are privacy, confidentiality and security (and, = more=20 recently, patient safety) and, for telehealth, they are licensure, = liability and=20 reimbursement.16 These have, to a large extent, usurped = the=20 limited policy debate, and the fact that they have remained unchanged = for over a=20 decade demonstrates the glacial pace of debate and action. Assuming that = inter-jurisdictional e-health is a desirable goal, attention must be = paid to=20 much more than these limited matters. In earlier (unpublished) work, I=20 identified 34 key e-health policy-related issues, and a recent paper = identified=20 almost 100 issues.17 A three-dimensional =91global e-health = policy=20 matrix model=92 is being developed as a tool to assist in understanding = this=20 complex setting18 (Figure 6.3). = This tool=20 highlights specific policy issues at the intersection of different = policy=20 levels, under specific policy themes, for specific policy = stakeholders.

3DImage=20

Figure 6.3 The three-dimensional = e-health=20 policy matrix model that highlights specific policy issues at the = intersection=20 of different policy levels, under specific policy themes, for specific = policy=20 stakeholders.

Definitive e-health policy is limited in scope, sparse = in=20 quantity and located primarily in a handful of industrialized countries. = In=20 other words, there is a global e-health policy void. Nascent e-health = policy=20 development can be identified in some countries, but is often indirectly = related=20 (information privacy policy) or focused on ICT rather than specifically=20 e-health. Tools for e-health policy research18, 19 and = development20,21 = have been=20 reported. In reality, it will be too much to expect rigid global = e-health=20 policy, and a format encompassing global e-health principles and = =91complementary=92=20 e-health policy20 is = much more=20 likely. This might be structured in the form of a global e-health = convention, as=20 originally suggested by Schwarz and adopted at the Rockefeller = conference on=20 e-health policy.22

Earlier expectations that global e-health might = revolutionize=20 the way in which we perform health care, and maximize our well-being, = have not=20 been realized. The recent resolution by the WHO may be a turning point, = drawing=20 the attention of domestic governments of member countries to the = potential of,=20 and need for, e-health in each of their countries. The next logical step = is to=20 focus that individual effort into the larger concept of global e-health. = Each=20 jurisdiction must accept that internal e-health policy cannot be = independent of=20 the international environment. This current policy fragmentation is as = much a=20 concern as the previously described policy void. An accepted strategy is = needed=20 that attends to global as well as local needs within a = responsive policy environment, giving rise to the idea of =91glocal=92 = e-health=20 policy.

=91Glocal=92 e-health policy development: = cautionary=20 examples

In any policy development, it is possible that = =91domestic=92=20 (i.e. local) policy decisions may prevent e-health from functioning on a = worldwide scale (i.e. global) by putting in place =96 inadvertently or=20 deliberately =96 administrative and policy barriers.20 = When=20 preparing their 1998 directive on protection of personal information, = the EU=20 commented that: =91If each Member State had its own set of rules on data = protection, for example on how data subjects could verify the = information held=20 on them, cross-border provision of services, notably over the = information=20 superhighways, would be virtually impossible.=92 This perspective = exemplifies the=20 need for =91glocal=92 e-health policy development.

Around the world, some policies have been developed = that affect=20 global e-health. These include:

the policy = environment in Africa, which illustrates coincidental policy = development;

the = European Union=92s=20 directive, and Canada=92s response (the Personal Information Protection = and=20 Electronic Documents Act, PIPEDA), which illustrate reactive policy=20 development;

the = e-health policy=20 implemented by Malaysia in the 1990s, which is an example of potentially = restrictive policy development;

the = Legally eHealth=20 initiative of the EU, which is an example of a potentially autocratic=20 approach.

The African policy = environment

Kirigia et al23 provided an optimistic view of the = e-health=20 policy environment in Africa, and concluded that the policy environment = for=20 e-health growth internationally was very encouraging. This was based on=20 observations of a number of international policies that encourage = sustainable=20 e-health usage, such as the World Health Assembly e-Health Resolution24 and the health-for-all policy for the = 21st=20 century.25

In addition, Kirigia et al23 pointed to =91regional development and = political=20 forums such as the New Partnership for Africa=92s Development (NEPAD),=20 sub-regional economic communities, regional development banks and the = United=20 Nations Economic Commission for Africa=92, each of which have = =91elements in their=20 policies and/or strategies encompassing ICT development=92. Finally, = they noted=20 the Blair Commission for Africa, which advocated massive investment in = ICT and=20 Internet connectivity and a =91growing realization among bilateral and=20 multilateral donor agencies of the need for supporting investments in = ICT=20 infrastructure and Internet connectivity in developing countries as an = essential=20 strategy for economic growth=92. In addition, the African Union=92s = strategy for=20 health in Africa lays out the planned development of health initiatives = until=20 2015.26

With the exception of the WHO resolution for e-health, = all of=20 the other documents refer to =91ICT=92 and not specifically to e-health. = While a=20 supportive ICT environment is needed, such policy is = coincidental to, and not focused on, e-health. Developing a clear, = supportive,=20 e-health-specific policy environment is necessary too.

EU directive on protection of personal=20 information

Ironically, as the EU prepared its 1998 directive on = protection of personal information, they also contributed to the = creation of=20 potentially restrictive policy. OECD guidelines for privacy protection = existed,=20 but the European Commission decided to promulgate their own directive. = This=20 directive compelled countries wanting to do business with EU countries = to have a=20 regulatory system in place to protect personal information, and required = businesses to adhere to =91fair information practices=92.

Lacking such legislation, Canada quickly introduced = its own=20 PIPEDA legislation in 2001 =96 a reactive response. But this also = affected=20 cross-border activities with Canada=92s largest trading partner, the = USA, since=20 they had to meet the specified requirements in order to do business with = Canada=20 and the EU. This form of reactive, snowball, and ad hoc policy = development is=20 inappropriate. Furthermore, it may well cause difficulties for = developing=20 countries, effectively setting the policy bar too high. If =91glocal=92 = e-health=20 policy is permitted to develop in this fashion, those countries that = could=20 benefit most may be excluded from the outset.

Malaysia=92s e-health = policy

Malaysia was very proactive in developing both = legislation=20 (e.g. the Telemedicine Act27) and guidelines (e.g. for = teleconsultation) for=20 domestic telemedicine. These were intended to broaden access to health = care in a=20 borderless fashion. They achieved this for domestic purposes, but may be = viewed=20 as restrictive for global e-health activities. For example, the section=20 =91Teleconsultation Beyond National Borders=92 states that =91Patients = and health care=20 professionals should be provided the opportunity to seek an expert = opinion and=20 treatment from overseas through teleconsultation=92. But then two = subclauses state=20 =91Foreign experts can provide teleconsultation to health care = professionals=20 and/or patients in Malaysia only at the invitation of the local = health care=20 personnel=92 and =91All overseas experts who are invited to provide = opinion or=20 who are referred cases must be registered with the appropriate = regulatory=20 authorities in Malaysia=92. Processes for invitation and/or = registration are=20 not provided, and penalties for transgression are severe, including = fines and=20 imprisonment.27 Such legislation raises potential = administrative=20 barriers to borderless global e-health initiatives.

EU initiative

In support of the European eHealth Action Plan, a = report=20 called Legally eHealth28 was intended to place e-health in a = European=20 legal and regulatory context. The report focused on how EU legislation = on data=20 protection, product and services liability, and trade and competition = law=20 applies. The report correctly noted that =91until these issues are = tackled head-on=20 in real cases, we will not begin to change the legal landscape in order = to=20 provide fertile ground for new developments=92. However, if the = resulting EU=20 e-health policy is implemented then once more the EU will be forcing = their requirements on the practice of global e-health. At the = very=20 least, such an approach will result in many years of retrospective = policy=20 realignment with other jurisdictions, maintaining rather than removing=20 inter-jurisdictional barriers to global e-health practice. At the worst, = it may=20 ostracize developing countries from the global e-health community. Such=20 approaches are not appropriate in the context of global e-health.

The way forward: a strategy

There are two basic policy options for global = e-health:

1. Continued ad hoc development followed by = policy=20 realignment. This is the status quo. It maintains the confusion and = prevents streamlined global e-health, and will require years of = retrospective=20 policy realignment to bring the many disparate approaches together. In = the=20 interim, many potential benefits of global e-health may be denied to the = world=92s=20 population.

2. Progressive and collaborative complementary = policy=20 development. A better approach, likely to permit the benefits of = global=20 e-health to be realized sooner, would be to initiate a process to guide = global=20 e-health policy development. The goal would be to identify common = principles=20 that can be agreed with relative ease, and then to use these to = encourage=20 development of domestic policy that is in line with global e-health = principles,=20 and is thereby complementary. The outcome would be removal of = administrative and=20 political barriers to global e-health.

Collaborative policy development would necessitate = the=20 creation of an inclusive and =91glocal=92 process whereby policy = implemented at each=20 level permits meaningful access to ICT in a country and therefore in the = health=20 sector. To guide this process, the Glocal E-health Policy Development = Framework=20 has been proposed.21

Conclusion

Global e-health has the ability to cross all = geopolitical,=20 socioeconomic, cultural and temporal barriers =96 to provide health and = health=20 care to anyone, anytime, anywhere. But how do we facilitate, yet also = manage,=20 this new paradigm? Any future activities have the potential to create = functional=20 or policy barriers. To avoid this, and to allow the benefits of global = e-health=20 to be equitably distributed, a coherent strategy is required that is = based on=20 both global and local (i.e. =91glocal=92) thinking.

The potential impact of global e-health is huge. = However,=20 awareness must be raised of the improvements in health care that could = be=20 achieved through global e-health. There is a need for consistency in = approach to=20 complex inter-jurisdictional issues. There is also a need for concerted=20 development of =91glocal=92 e-health principles and complementary = domestic policy.=20 The current global e-health policy void is a serious concern. = Inappropriate=20 policy developed in one jurisdiction could hamper the ability of = e-health to=20 fulfil its potential.

Global e-health is no different from any other tool. = To use this=20 tool for global good requires a common vision and = collective=20 determination to achieve that vision. At present, e-health is struggling = to=20 establish itself even on a local or national basis in many countries,=20 particularly developing countries. Policy can determine the pace and = direction=20 of change. If the potential of global e-health is to be realized, a = strategy is=20 required that will identify globally acceptable principles and thereby = allow=20 complementary domestic policy to be developed.

References

1.=20 Institute of Medicine. America=92s Vital Interest in Global = Health.=20 Washington, DC: National Academy Press, 1997.

2.=20 Scott RE, Palacios MF. E-health =96 challenges of going global. In: = Scott CM,=20 Thurston WE, eds. Collaboration in Context. Calgary: Institute = for=20 Gender Research and Health Promotion Research Group, University of = Calgary,=20 2003.

3.=20 MacPherson DW, Gushulak BD. Human mobility and population health: new = approaches=20 in a globalizing world. Perspect Biol Med 2001; = 44:=20 390=96401.

4.=20 Kaul I, Faust M. Global public goods and health: taking the agenda = forward.=20 Bull World Health Organ 2001; 79: = 869=9674.

5.=20 World Health Organization. Macroeconomics and Health: Investing in = Health=20 for Economic Development. Available at:=20 whqlibdoc.who.int/publications/2001/924154550X.pdf.

6.=20 Dodgson R, Lee K, Drager N. Global Health Governance: A Conceptual=20 Review. Available at:=20 whqlibdoc.who.int/publications/2002/a85727_eng.pdf.

7.=20 Bettcher D, Lee K. Globalisation and public health. J. Epidemiol = Community=20 Health 2002; 56; 8=9617.

8.=20 Rigby M. The management and policy challenges of the globalisation = effect of=20 informatics and telemedicine. Health Policy 1999; = 46:=20 97=96103.

9.=20 Scott RE, Lee A. E-health and the Universitas 21 organization: 3. Global = policy.=20 J Telemed Telecare 2005; 11: 225=969.

10. Bill and = Melinda=20 Gates Foundation. Foundation Fact Sheet. Available at:=20 www.gatesfoundation.org/MediaCenter/FactSheet/.

11. World = Health=20 Organization. Policy and Budgets for One WHO. Available at:=20 ftp.who.int/gb/archive/e/e_ppb2003.html.

12. Scott RE, = Jennett=20 P, Yeo M. Access and authorisation in a glocal e-health policy context. = Int=20 J Med Inform 2004; 73: 259=9666

13. Bashshur = RL. Health=20 policy and telemedicine. Telemed J 1995; 1: = 81=963.

14. Gobis LJ. = Licensing=20 and liability: crossing borders with telemedicine. Caring 1997; = 16: 18=9624.

15. White AW, = Wager KA,=20 Lee FW. The impact of technology on the confidentiality of health = information.=20 Top Health Inf Manage 1996: 16; 13=9621.

16. Stanberry = B. Legal=20 and ethical aspects of telemedicine. J Telemed Telecare 2006;=20 12: 166=9675.

17. Khoja S, = Durrani H,=20 Fahim A. Scope of Policy Issues for eHealth: Results from a = Structured=20 Review. Available at:=20 ehealth-connection.org/files/conf-materials/ScopeofPolicyIssuesforeHealth= _0.pdf

18. Scott RE. = Investigating e-health policy =96 tools for the trade. J Telemed = Telecare=20 2004; 10: 246=968.

19. Varghese = S, Scott=20 RE. Categorising the telemedicine policy response of countries and their = implications for complementarity of telemedicine policy. Telemed J E = Health 2004; 10: 61=969.

20. Scott RE, = Chowdhury=20 MFU, Varghese S. Telemedicine policy =96 looking for global = complementarity. J=20 Telemed Telecare 2002; 8(Suppl 3): 55=967.

21. Scott RE. = =91Glocal=92 e-Health =96 A Conceptual Policy Development = Framework.=20 Available at: www.mrc.ac.za/conference/satelemedicine/Scott3.pdf.

22. = Rockefeller=20 Foundation. National eHealth Policies =96 an Overview. = Available at:=20 ehealth-connection.org/content/national-ehealth-policies-an-overview.

23. Kirigia = JM, Seddoh=20 A, Gatwiri D et al. E-health: determinants, opportunities, challenges = and the=20 way forward for countries in the WHO African Region. BMC Public = Health=20 2005; 5: 137.

24. World = Health=20 Organization. WHA58.28 e-Health. Available at:=20 www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_28-en.pdf.

25. World = Health=20 Organization. Health-for-All Policy for the Twenty-First Century = (Resolution=20 WHA51.7). Available at: = www.paho.org/English/GOV/CSP/csp25_27.pdf.

26. African = Union.=20 Africa Health Strategy 2007=962015. Available at:=20 www.africa-union.org/root/UA/Conferences/2007/avril/SA/9-13%20avr/doc/en/= SA/AFRICA_HEALTH_STRATEGY_FINAL.doc.

27. Malaysian = Government. Laws of Malaysia, Act 564, Telemedicine Act, 1997.=20 Available at: www.parlimen.gov.my/actindexbi/pdf/ACT-564.pdf.

28. European=20 Commission. Legally eHealth. Putting eHealth in its European Legal=20 Context. Available at:=20 ec.europa.eu/information_society/activities/health/docs/studies/legally-e= health-report.pdf.

7 Experiences and lessons learnt from = telemedicine projects=20 supported by the IDRC

Laurent Elder and Michael = Clarke

Introduction

In 1970, Lester B Pearson, then Prime Minister of = Canada and a=20 strong proponent of international development, stated the need for =91a = new=20 instrument concentrating more attention and resources on applying = technology to=20 the solution of =85 economic and social problems on a global basis=92.1 In May 1970, the International = Development=20 Research Centre (IDRC) was founded by an act of the Canadian parliament. = One of=20 the Centre=92s priorities was Information and Communication Technologies = for=20 Development (ICT4D), since access to information and an effective means = to=20 communicate are necessary for sustainable development. IDRC=92s ICT4D = programme=20 now supports projects in Africa, Asia, Latin America and the Caribbean = at a cost=20 of nearly Can$20 million each year.

Exploring the means by which information and = communication=20 technology (ICT) can solve health problems was part of IDRC=92s early = work in=20 ICT4D. The IDRC was interested in answering questions such as the = following:

How can = ICTs play a=20 role in providing health care services to rural and remote regions of = developing=20 countries?

Which = applications=20 afford the most potential with respect to effectiveness, adaptability = and=20 sustainability?

What are = the=20 challenges to setting up e-health programmes in developing = countries?

How do = different=20 user groups access and use these programmes?

Early work

Much of the work supported by IDRC in the 1990s in = the area of=20 health and ICT focused on the development of health information systems. = It=20 included projects such as the Latin American Health Information Network, = the=20 National Health Information Network (Colombia) and HealthNet. The IDRC = also=20 supported the application of geographical = information systems=20 for mapping malaria risk in Africa, for endemic disease control in = Botswana and=20 Senegal, and for malaria control in the Amazon Basin. Telemedicine = projects did=20 not begin until the late 1990s, because of the generally poor = telecommunications=20 infrastructure in developing countries. It was not until the Internet = started to=20 become available in developing countries that IDRC began to investigate = the=20 potential of telemedicine.

Telemedicine in Uganda

An early project to establish telemedicine in Uganda = began in=20 2000. The project, which received Can$452 300 in funding, focused on = health=20 problems such as cholera, malaria, HIV/AIDS and the application of = telemedicine=20 to address them. To achieve this, Makerere University School of Medicine = aimed=20 to establish telemedicine centres at Mulago and Butabika, set up the=20 telemedicine infrastructure in the centres, conduct online consultations = with=20 the rural centres and start a continuing medical education = programme.

What actually happened? As was typical of early = telemedicine=20 projects in Africa, there were difficulties in procuring appropriate=20 telemedicine equipment and in setting up the telecommunications, which = were=20 based on VSAT. (A very small-aperture terminal, or VSAT, is a two-way = satellite=20 ground station with a dish antenna.) No online consultations actually = took place=20 between Kampala and the rural health centres, and there was no evidence = of any=20 beneficial health outcomes for the rural population.

None the less, with the support of Memorial University = in=20 Canada, the telemedicine in Uganda project helped to train staff in = telemedicine=20 activities. It also helped to focus government attention on rural health = problems and it developed educational materials that are still used to = this day.=20 The project also contributed valuable lessons for future e-health = projects. It=20 set the stage for more successful e-health projects in Uganda, such as = the=20 Uganda Health Information Network and a subsequent telemedicine project = in=20 Mengo.

As far as IDRC was concerned, the project helped the=20 organization better understand the challenges of supporting telemedicine = projects in Africa and helped define some of the key questions that it = would try=20 to answer. These questions included how appropriate local capacities = should be=20 built, both technical and institutional. Second, there was a need to = focus on=20 =91e-readiness=92, which is the state of a country=92s ICT = infrastructure and the=20 ability of its consumers, businesses and governments to use ICT for = their=20 benefit. Finally, the IDRC needed to think about how it could help = answer the=20 key underlying question: is telemedicine a viable method for solving = health=20 problems in developing countries? In the Uganda project, cost=96benefit = analyses=20 had not been conducted and health outcomes had not been measured, mainly = because=20 of the problems of implementing the pilot. All of these lessons helped = shape=20 IDRC=92s thinking about supporting the development of effective health=20 applications (see below).

E-health applications in = Asia

The IDRC programme, Pan Asia Networking (PAN), = supports=20 research into new ways of using ICT in the areas of health, education,=20 livelihoods and governance.2 Most of

Table 7.1 Telemedicine and = e-health=20 projects funded by the PAN Asia small grants = programme
Country	Project	Organization	Grant (US$)
India	ICT-enabled life skill and sexuality education = for=20 adolescent girls	Centre for Women=92s Development and = Research	8911
India	Using ICT to build capacities of HIV/AIDS = service=20 providers in India	SAATHII (Solidarity and Action Against The HIV = Infection=20 in India)	29 786
India	Impact of remote telemedicine in improving = rural health,=20 India	n-Logue Communications Pvt Ltd	29 313
Indonesia	Development of ICT-based telemedicine system = for primary=20 community health care in Indonesia	Biomedical Engineering Program, Department of = Electrical=20 Engineering, Institut Teknologi Bandung (ITB)	29 479
Indonesia	Development of ICT-based mobile telemedicine = system with=20 multiple communication links for urban and rural areas in = Indonesia	Biomedical Engineering Program, Department of = Electrical=20 Engineering, Institut Teknologi Bandung (ITB)	29 479
Nepal	Telemedicine in Nepal: a pilot project	HealthNet Nepal	30 000
Pakistan	ICT-assisted learning tool for the deaf in=20 Pakistan	Sustainable Development Networking Programme,=20 Pakistan	28 500
Philippines	A community-based child injury surveillance = system: rapid=20 data collection using SMS	Medical Informatics Unit, College of Medicine, = University=20 of the Philippines	22 642
Philippines	Mobile telemedicine and information resource = system for=20 community health workers	SynapseHealth Solutions, Inc	29 784

the activity related to health occurs in the PAN = R&D=20 Grants Program.3 An example is the Pan Asian = Collaborative for=20 Evidence-Based eHealth Adoption and Applications (PANACeA) project, = discussed in=20 greater detail below. The health-related projects that have been funded = are=20 summarized in Table=20 7.1. Some recent evaluations have helped to shed light on the = outcomes of=20 some of these projects.4 There were two activities related to = telemedicine=20 in India and Indonesia.

The first project concerned the impact of telemedicine = on rural=20 health in selected villages in India. The project aimed to field test = with the=20 help of N-Logue,5 a low-cost medical kit, called = ReMeDiTM. The=20 equipment was developed by Neurosynaptic Communications Pvt Ltd6 and installed in rural Internet kiosks = around=20 Tirupattur. The object was to transmit medical information to a doctor = in=20 Tirupattur.

After the service was launched, there was an increase = in the=20 number of visitors to the kiosk. However, following the initial = interest, the=20 number of visitors dropped precipitously to a few regular, repeat = visitors. The=20 drop was explained by the following factors: the kiosk operator=92s = ability to=20 administer the equipment properly; acceptability by the villagers;=20 identification of the kiosk in a place where medical care is already = dispensed;=20 lack of awareness of the service; distance of the doctor from the = village; and=20 availability of competing services such as Registered Indian Medical=20 Practitioners, Primary Health Centres and local doctors.4 Although the project was not able = to

3DImage=20

Figure 7.1 Indonesian mobile = telemedicine=20 application being demonstrated

3DImage=20

Figure 7.2 Indonesian mobile = telemedicine=20 application

document any health outcomes, it was =96 contrary to = the Ugandan=20 experience =96 able to demonstrate actual telemedicine activity.

The second project, in Indonesia, was to develop a = telemedicine=20 system for primary community health care. It was based on existing = Internet=20 technology to enhance PC-based medical stations. The pilot telemedicine = network=20 consisted of six medical stations in community health centres, and a = station for=20 the referral hospital, health office and a test laboratory. The system = included=20 teleconsultation and telediagnosis applications, medical information = display=20 software, a blood pressure and fetal heart rate interface, and an ECG = interface=20 (Figures = 7.1 and 7.2).

It was found that human resource capacity building, in = particular training to facilitate computer and telemedicine adoption, = required=20 substantially more time than expected. The project therefore = demonstrated the=20 significant role that human resource development plays in the = implementation of=20 telemedicine systems. However, as before, no findings were documented on = the=20 effect that the pilots had on people=92s health or health systems.

In a report commissioned by IDRC, the projects listed = in Table 7.1 were = assessed=20 in order to evaluate their outcomes.7 The factors examined were:

knowledge = production=20 =96 any type of publication

research = targeting,=20 capacity building and absorption =96 follow-on research, training of = staff

e-health = solution=20 adoption or integration =96 expansion or adoption of an e-health = solution

informing = policy =96=20 policy documents, meetings with government officials

broader = community,=20 institutional, or country benefit =96 including social and economic = benefit

health = benefits to=20 individuals or the population =96 more effective health care.

All projects were then ranked in terms of health = outcomes and=20 common themes were identified. The most troubling common theme was that = all=20 projects ranked =91low=92 with respect to demonstrated health = benefits.

When Scott compared the projects, he saw that several = common=20 deficiencies had an adverse effect on nearly all of them. The = deficiencies=20 included:7

Lack of planning for a sound, strategic health = needs=20 assessment, lack of planning for sustainability of (proven) solutions, = lack of=20 consideration for and mitigation of change management issues, lack of = sound=20 evaluation planning or execution, limited or no dissemination (formal or = informal) of findings, and no significant or structured knowledge = translation=20 and transfer to influence decision- or policy-making around future = e-health=20 implementations. =85 In addition, several general issues came to light, = which also=20 will need to be addressed. These included considerations around = application=20 software (i.e. open source versus proprietary solutions), application = focus=20 (e.g. use of traditional versus more novel technology such as GIS or = m-health=20 tools8), and local e-health knowledge and = expertise=20 (i.e. need for skill transfer and capacity building).

Present work

The early telemedicine projects that IDRC supported = did not=20 achieve all that was expected of them and raised more questions than it=20 answered. Present projects include work in Africa and Asia.

Eastern and southern = Africa

In 2004, the AfriAfya organization9 undertook a study in eastern and = southern Africa=20 in conjunction with other African partners. The project was designed to = study=20 the application of ICT in the HIV/AIDS response in Uganda, Kenya, = Tanzania,=20 South Africa and Botswana. After conducting a literature review, the = project=20 staff undertook an electronic survey of individuals and organizations = involved=20 in HIV/AIDS matters. There were 990 respondents in a face-to-face survey = undertaken in Tanzania and South Africa.

Unsurprisingly, the study found that South Africans = and=20 Tanzanians generally obtained their information on antiretroviral = treatment=20 (ART) from traditional media, rather than new media (Table 7.2). = However, a=20 surprisingly high proportion (30%) of South Africans obtained = information from=20 mobile phones and SMS. The assumption is that, as access to mobile = telephony and=20 the Internet rises in Africa, so will the number of people accessing = health=20 information from mobile phones.

According to the survey, illiteracy ranked highest of = the=20 factors impeding the use of ICT in both Tanzania and South Africa = (although all=20 factors scored highly in the latter). The results echo most of the = research done=20 by IDRC, which shows that illiteracy and localization matters are = generally seen=20 as among the most important factors impeding the more widespread use of = ICT (Table = 7.3).

Table 7.2 Sources of = information on=20 antiretroviral therapy.10 = Values=20 shown are percentages of sample (n =3D 990)
ICT	South Africa (%)	Tanzania (%)
Print	75	53
Radio	88	81
TV	83	50
Video	21	20
Audiotapes	17	18
Telephones	24	4
Face-to-face meetings	77	82
Mobile phones and SMS	31	10
Computer/CDs	23	3
Email	22	2
Internet	25	2

Table 7.3 Factors impeding = the use of=20 ICTs for the fight against HIV/AIDS.10 = Values=20 shown are percentages of sample (n =3D 990)
Factor	South Africa (%)	Tanzania (%)
Inappropriate language	81	58
Inappropriate and embarrassing = messages	73	49
Lack of information, education and = communication=20 materials	80	81
Lack of feedback mechanism	82	67
Lack of enabling ICT policies	82	63
Poor infrastructure/physical access	86	80
People=92s attitudes	85	75
Traditional/cultural beliefs	87	80
Cost	85	68
Illiteracy	90	81

Table 7.4 Effectiveness of = ICTs.10 = Values=20 shown are percentages of sample (n =3D 990)
ICT	Don=92t know (%)	Harmful (%)	Extremely = effective (%)
Print	7	2	46
Radio	2	8	65
TV	6	2	54
Video	30	6	14
Audiotapes	39	3	9
Telephone	43	3	8
Face-to-face meetings	6	3	61
Mobile phones/SMS	31	3	13
Computer/CDs	52	5	8
Email	59	5	9
Internet	56	9	10

The respondents perceived that radio, print media and = TV, as=20 well as face-to-face meetings, were =91extremely effective=92. However, = the majority=20 of respondents did not know whether computers, email and the Internet = could be=20 effective (Table=20 7.4). Strangely, almost 9% saw the Internet as =91harmful=92, the = highest=20 percentage in that category. One can question the methodology of a = perception=20 questionnaire, as well as the terms used. For example, what does = =91harmful=92=20 actually mean? What is meant by =91extremely effective=92? However, one = cannot deny=20 that conventional communication methods are still perceived as the most = widely=20 used modes of information transmission.

Finally, according to the AfriAfya study, the best = practices for=20 using ICT in the fight against HIV/AIDS were:

1. Use of mobile phones and SMS

2. ICT for up-to-date HIV management information

3. ICT for mobilization

4. A combination of different forms of ICT

5. Telephone counselling.

The main lessons from this research were: that the = use of=20 =91modern=92 ICT is still very limited, but that there is huge = potential; that=20 institutions and health workers remain reliant on =91conventional=92 ICT = and that=20 there is therefore a need to integrate both =91modern=92 and = =91conventional=92to obtain=20 the best results; and, perhaps most important, that to change = perceptions and=20 behaviours requires careful planning and patience.

Acacia project

Most mobile telecommunications infrastructure in = Africa is too=20 slow and expensive for connecting computers to the Internet. However,=20 low-bandwidth applications have emerged that use mobile phones or = personal=20 digital assistants (PDAs) such as Palm Pilots, to connect via mobile = networks.=20 While information designed and formatted for the web is generally too = bandwidth=20 intensive to be transmitted over mobile networks, it can be formatted = for small=20 devices and low-bandwidth transmission. PDAs and smart phones are also = seen as=20 advantageous because of their robustness (no moving parts), their = relative=20 affordability, and their ability to be maintained in areas with little = or no=20 electricity infrastructure through the use of solar power rechargers. = Examples=20 of Acacia-supported mobile-enabled health applications include:

automation = of=20 demographic surveillance activities, such as those at the core of = pioneering=20 health care initiatives, for example the Tanzanian Essential Health=20 Interventions Project;10

the use of = SMS=20 reminders in the treatment of tuberculosis in Cape Town; 11

delivery = of=20 continuing medical education and professional development via PDAs;12

delivery = of=20 time-sensitive alerts to patients and health workers;

= maintenance of=20 patient records for HIV-positive patients=92 lifelong drug = treatments;

management = of=20 specific health care initiatives such as the roll-out of ART and = tuberculosis=20 treatment initiatives.13

The IDRC programme Acacia has funded projects in all = of these=20 areas. The main research questions are:

What are = the most=20 effective, relevant, affordable and scalable technologies to facilitate = mobile=20 health delivery?

Can = mobile-enabled=20 health services and applications reduce the costs of health service = management=20 and delivery? What is the cost=96benefit of using these = applications?

What kinds = of health=20 services can best be enabled through a mobile infrastructure?

How are = economies of=20 scale being realized across the continent, and how can innovations be = shared=20 between African countries?

What are = the social=20 effects of the introduction of these technologies in rural areas?

What is = the=20 relationship between mobile health applications and broadband = technologies,=20 including VSAT?

Pan Asia Networking

In the Pan Asia Networking programme, more pervasive = technologies, such as mobile phones and PDAs, are expected to be = important for=20 health applications.14 Since mobile phone use is more = widespread in=20 Asia than in Africa, it is clear that there is great potential in Asia. = The PAN=20 programme emphasizes that more research is needed to gauge which = applications=20 and projects in the area of health have made a difference, to understand = why=20 they have or have not been successful, and, when warranted, to scale = them up.=20 However, the fast pace of innovation in both ICT and health research = means that=20 there is also a need for developing, implementing and evaluating new=20 applications, particularly in the area of demographic surveillance of = disease=20 incidence and medical compliance, using new technologies such as mobile=20 devices.

Another important matter in Asia is pandemics. Severe = acute=20 respiratory syndrome (SARS) and Avian influenza are serious threats to = the=20 health of Asians, as well as the rest of the world. A key to reducing = the spread=20 of these infectious diseases is to ensure that appropriate information = on=20 outbreaks is captured and communicated to the relevant experts as = quickly as=20 possible. ICT can therefore play an important role in helping to prevent = or=20 control pandemics, although more research and experimentation are needed = to=20 identify the best means of communication in rural and remote areas, = where many=20 of these outbreaks begin.

The questions that PAN would like to answer are:

Which ICT = health=20 applications have had the most beneficial outcomes on people=92s health = and health=20 systems? What are the best ways of ensuring that beneficial outcomes can = reach=20 the segment of the population that does not have adequate access to = health=20 services?

What is = the=20 potential of using new pervasive technologies, such as mobile phones, to = make=20 the delivery of health services or information more effective?

What types = of=20 applications are best suited to help prepare for, or mitigate the = effects of,=20 pandemics such as SARS and Avian influenza?

PANACeA project

The PANACeA project (Pan Asian Collaborative for=20 Evidence-Based eHealth Adoption and Application) will support research = on=20 e-health solutions in Asia. The research programme includes:

a portable = system=20 for telemedicine and health information in rural and remote areas;

a pilot = programme in=20 Mongolia and the Philippines of remote consultation to improve health = services=20 for rural mothers;

a = disaster/emergency=20 telemedicine system;

a = cost=96benefit=20 analysis of hospital information management system data mining and data=20 warehousing;

an = evidence-based=20 approach to mainstreaming e-health initiatives in primary care;

basic = intervention=20 research on e-health for persons with disabilities;

online = tuberculosis=20 diagnostic committees for clinically suspect, sputum-negative patients = in the=20 TB-DOTS programme;

use of = mobile phones=20 for referral of pregnant women.

The research programme also includes research = activities such=20 as reviews of telemedicine and health informatics in Asia.

Future work

IDRC will continue to support research and = development=20 projects in telemedicine and e-health in its next five-year planning = cycle=20 beyond 2010. Sufficient evidence has been generated from work carried = out by=20 IDRC partners and others to show that implementing telemedicine and = e-health=20 applications can have many benefits, including direct benefits to = patients. The=20 benefits include reductions in medical errors, cost savings, real-time=20 monitoring of public health incidents, and provision of validated data = and=20 information for health systems decision and policy making. However, = there is a=20 continuing need to support research that demonstrates these benefits = within the=20 framework of a cost=96benefit analysis in order to justify the often = substantial=20 initial investments associated with telemedicine. This, of course, is=20 particularly significant in the context of developing countries with = limited=20 financial resources and telecommunications infrastructure.

Telemedicine and e-health applications that are shown = to be=20 appropriate, affordable and effective in one region can be adopted in = other=20 regions, provided that they are localized and contextualized. This = should be=20 within the capacity of the networks of ICT workers and researchers that = IDRC now=20 supports around the world.

IDRC=92s work on telemedicine and e-health research in = developing=20 countries depends on innovation. Unfortunately, in several projects,=20 satisfactory results were not achieved, for the reasons indicated above. = However, it should be noted that the average failure rate for ICT = projects is=20 about 50%15 and is no different in the health care = sector=20 specifically.16 Such high failure rates are not = acceptable in=20 most countries. The research that IDRC supports in this area should = improve the=20 likelihood of success.

Our research programmes will also continue to respond = to=20 emerging technologies and markets. As pointed out above, we have = developed a=20 number of research collaborations focusing on the use of mobile = telephony as a=20 device for the monitoring, management and delivery of health care. The = needs of=20 people living in developing countries are evident, = but,=20 ultimately, depend on a healthy society with full access to effective = health=20 care. IDRC is committed to helping them achieve just that.

References

1.=20 IDRC. History of IDRC. Available at:=20 www.idrc.ca/en/ev-26547-201-1-DO_TOPIC.html.

2.=20 IDRC. Pan Asia Networking. Available at: www.idrc.ca/pan.

3.=20 IDRC. ICT R&D Grants Programme. Available at:=20 www.idrc.ca/panasia_grants/.

4.=20 Dougherty M. Exploring New Modalities. Experiences with Information = and=20 Communications Technology Interventions in the Asia=96Pacific = Region.=20 Bangkok: UNDP Asia=96Pacific Development Information Programme, 2006. = Available=20 at: = www.idrc.ca/uploads/user-S/11685405431ExploringNewModalities.pdf.

5.=20 N-Logue Communications Pvt Ltd. N-logue. Available at:=20 www.digitaldividend.org/case/case_nlogue.htm.

6.=20 Neurosynaptic Communications Pvt Ltd. ReMeDi. Available at:=20 www.neurosynaptic.com.

7.=20 Scott R. IDRC Internal Report, 2006 (available from the authors).

8.=20 MoHCA. Mobile Healthcare Alliance. Available at:=20 www.mobilehealthcarealliance.org/index.shtml.

9.=20 IDRC. The Impact of ICTs in HIV/AIDS Programs in Eastern and = Southern=20 Africa. Available at: = www.idrc.ca/en/ev-87732-201-1-DO_TOPIC.html.

10. IDRC. = Tanzania=20 Essential Health Interventions Project (Archive). Available at:=20 www.idrc.ca/en/ev-3170-201-1-DO_TOPIC.html.

11. = Bridges.org.=20 Testing the Use of SMS Reminders in the Treatment of Tuberculosis in = Cape=20 Town, South Africa. Available at: = www.bridges.org/publications/11.

12. IDRC. = Uganda=20 Health Information Network (UHIN). Available at:=20 www.idrc.ca/en/ev-86353-201-1-DO_TOPIC.html.

13. IDRC. = Free=20 State HIV Therapy Database (ART-HIV). Available at:=20 www.idrc.ca/en/ev-86361-201-1-DO_TOPIC.html.

14. IDRC. = PAN=20 Prospectus 2006=962011. Available at:=20 www.idrc.ca/en/ev-9622-201-1-DO_TOPIC.html.

15. IT = Cortex.=20 Failure Rate: Statistics over IT Projects Failure = Rate.=20 Available at: www.it-cortex.com/Stat_Failure_Rate.htm.

16. Gauld R. = Public=20 sector information system project failures: lessons from a New Zealand = hospital=20 organization. Government Information Quarterly 2007;=20 24: 102=9614.

8 Strategies to promote e-health and telemedicine = activities in developing countries

Sisira Edirippulige, Rohana B Marasinghe, = Vajira H W=20 Dissanayake, Palitha Abeykoon and Richard Wootton

Introduction

Logic suggests that employing information and = communication=20 technology (ICT) to deliver health care at distance (i.e. telehealth or=20 e-health) would be useful to address at least some of the problems in = developing=20 countries. There is a growing body of literature to attest to this = argument.1=963 In = the early=20 1990s, there was a general expectation that e-health would solve the = main=20 problems in health care in developing countries. However, the progress = actually=20 made with e-health in developing countries has been rather limited to = date. It=20 is also true that the use of e-health in industrialized countries is = limited.4

What are the factors that have prevented developing = countries=20 from using e-health? What strategies might promote the use of = e-health?

Role of national governments in=20 promoting
e-health

Governments as policy-making organizations play a = pivotal role=20 in formulating regulations in the health sector. The contribution of the = government is particularly important in developing countries, where the = public=20 health system is usually the major provider of services. Government = policies=20 often have a significant impact on governing, financing and regulating = the=20 health sector in developing countries.5

Most developing countries in recent years have = recognized the=20 importance of ICT in their economic development and social progress.6=968 A = number of=20 countries in the developing world have initiated national policies = towards=20 integrating ICT into their economic plans.9=9612 = However, it=20 is surprising that, in most cases, these national ICT initiatives have not considered the health sector as an = important=20 sector.

We believe that the exclusion of the health sector in = national=20 ICT initiatives is a major cause of the slow progress of e-health in = developing=20 countries. The factors contributing to this situation are described = below.

Reasons for non-adoption of = e-health

The reasons for the non-adoption of e-health = include:

lack of = awareness of=20 the benefits among policy makers

lack of = evidence for=20 the benefits

limited = finance

= prejudice

lack of=20 expertise

health = system=20 inertia.

First, we assume that one powerful reason for this = situation=20 is a lack of awareness of policy makers about the benefits of = e-health.13 Although policy makers in developing = countries=20 commonly believe that ICT can be used in the development of industry,=20 agriculture and other economic and social activities, they are not aware = of the=20 benefits that the health sector can derive through the use of ICT. There = can be=20 many reasons for this. The health/medical sector is a very sensitive = area where=20 traditional ways of working have evolved over centuries and, as a = result, there=20 is resistance to change. Health is also closely linked with privacy and = security=20 concerns. Therefore, the introduction of ICT into health care = institutions may=20 not be as straightforward as in other sectors, such as commerce and=20 education.

Lack of evidence about the benefits of e-health may be = another=20 reason for policy makers being unaware of e-health. Even in = industrialized=20 countries, there is a dearth of hard evidence with regard to the = successful use=20 of e-health. Similar evidence from developing countries is even scarcer. = The=20 lack of a sustainable business case to demonstrate cost-effectiveness is = the=20 root cause.

Although policy makers in developing countries are = aware of the=20 benefits of e-health, for a range of reasons they are reluctant to = include this=20 tool in their ICT initiatives. First, this may be due to limited = financial=20 capability. Policy makers are more likely to spend their limited = resources on=20 interventions that are known to produce health gain, such as sanitation, = clean=20 drinking water and vaccination, rather than funding e-health projects. = The=20 critical state of the health sector and its financial limitations may = not allow=20 policy makers to change their traditional patterns of spending health = funding,=20 even when they are aware of the benefits of e-health. In some of the = wealthier=20 developing countries that have good health care services, there seems to = be a=20 lack of people within the health sector who can champion the cause of = e-health=20 with policy makers.

Reluctance to use e-health may also stem from certain=20 prejudices. Policy makers in developing countries may regard e-health as = a=20 family of methods imported from the industrialized world that have = little=20 relevance in their own countries. E-health may even = be seen as=20 the imposition of new methods from the Western world or former colonial=20 authorities, i.e. as a form of neocolonialism.

Even when they have an understanding of the benefits = of=20 e-health, policy makers in developing countries may be hesitant to use = it owing=20 to a lack of expertise, infrastructure, technical knowledge and = skills.14,15 Starting an e-health project requires = the=20 presence of people with a certain level of technical expertise, and this = may not=20 be available in many developing countries.16 In addition, the telecommunication=20 infrastructure in developing countries is still limited.17 These factors make it difficult for = developing=20 countries to launch e-health projects on their own.

Aspects such as inertia, reluctance to change and a = lack of=20 political will are also important factors that prevent policy makers = from=20 considering e-health as an alternative for addressing health problems in = developing countries. Reluctance to change traditional methods of = practice has=20 been a serious obstacle to integrating e-health in the industrialized = world=20 too.18 The introduction of a new practice is = always=20 demanding, and in that respect the role of champions or enthusiasts is = extremely=20 important. The lack of such champions in policy-making circles may be a = strong=20 reason for the current situation.

Another important factor, perhaps due to a combination = of the=20 factors mentioned above, is the need for long-term investment in = telehealth and=20 e-health, in order to build an infrastructure and the human resources = required=20 to demonstrate success. This is impeded by the relatively short = political cycle,=20 which requires short-term political rewards for investments.

Strategies at national level

Strategies to promote e-health at national level = include:

raising = awareness of=20 policy makers

expanding = e-health=20 education

changing = the=20 attitude of policy makers

using = expatriate=20 communities.

One way of addressing the problems outlined above is = to alert=20 policy makers to the benefits of e-health. There needs to be a = systematic way of=20 making them aware of the current state of e-health practice and = successful=20 applications. It is important to make them aware of aspects of e-health = that are=20 applicable in developing countries. To do so, improving access to the = evidence=20 base in e-health is extremely important. Making updated information = about=20 successful e-health projects available to policy makers is one way of = achieving=20 this goal. Enthusiasts within the health sector, both IT and health=20 professionals, may also play a pivotal role in making policy makers = aware of the=20 benefits of e-health.

The importance of e-health education has so far been = overlooked.=20 Evidence shows that access to systematic education in e-health is = limited in=20 both industrialized and developing countries.16,19 Systematic education in e-health for = health=20 personnel must be at the heart of any strategy designed to facilitate = e-health.=20 An understanding of the benefits of e-health, = current=20 applications, technical requirements and the ethical/legal aspects would = enable=20 health professionals to adopt this new technique. In this task, local = academics=20 and researchers can play an important role. It is important to encourage = academics to publish the outcomes of any e-health projects = internationally. By=20 doing so, local academics and health scientists can influence policy = makers to=20 facilitate the wider use of e-health.

On the other hand, policy makers must adopt an = open-minded=20 approach to these new changes. Political will and commitment, which have = often=20 been lacking in developing countries, are important elements in bringing = about=20 changes in these societies. The willingness of policy makers to use ICT = in=20 health is important in integrating this tool into the health sector.

While the continuing brain drain is a serious problem = in=20 developing countries, little attempt has so far been made to use = expatriate=20 communities to the benefit of the development of these countries. This = is=20 certainly not a problem specific to e-health. However, in promoting = e-health,=20 expatriate experts (particularly experts in the areas of health and ICT) = can=20 make a significant contribution by bringing their knowledge, skills and=20 expertise. Mobilization of experts from expatriate communities must be = promoted,=20 as these people have knowledge and skills not only in the subject area, = but also=20 about specific needs and cultural issues. From the policy makers=92 side = there=20 must be an attitudinal change to accept and facilitate these = experts.

In any environment, however, change is driven by = individuals who=20 have the motivation and desire to do so. In countries such as Sri Lanka, = where=20 national level e-health initiatives have lagged behind, there are = numerous=20 anecdotal examples of successful institutional level initiatives driven = by such=20 champions of e-health. Thus, it is clear that what is lacking in some = countries=20 is not resources or finances but leadership. Identifying such = individuals within=20 the heath care system of the country and providing the necessary support = to them=20 to bring about the desired change are very important.

Role of international agencies

International agencies such as the World Health = Organization=20 (WHO), the United Nations (UN), the World Bank and certain regional=20 organizations (e.g. the African Union and SAARC) have recognized the = value of=20 ICT in development.20=9622 In = fact the=20 WHO has been instrumental in promoting e-health in a number of ways.23 Some of these organizations have been = involved=20 in e-health projects in different parts of the world.24

Regardless of the enthusiasm of these organizations = for=20 e-health, their activities have so far been piecemeal and fragmented. In = most=20 cases, the primary responsibility of these organizations has been = limited to=20 providing funds. Often, the outcome of these initiatives has been = unhappy: once=20 the initial funding dried up, the e-health projects stopped = functioning.24 Another feature of these projects has = been their=20 disconnectedness. That is, most of them have functioned in isolation, = and have=20 not had links to other health work within the region concerned. There = may be a=20 number of factors contributing to this situation. International = organization(s)=20 initiating e-health projects in developing countries = often=20 have very limited understanding of the local situation. They may also = have=20 limited authority and recognition.

Another feature of e-health projects undertaken in = developing=20 countries is that they are commonly nothing more than a replication of = projects=20 carried out in industrialized countries. There is often no attempt to = understand=20 the specific needs of the locality and to find appropriate solutions to = address=20 those needs.

Thus, one of the main problems with international = involvement=20 in developing countries undertaking e-health projects has been a lack of = coordinated management. This certainly invites another important = question: =91Who=20 should drive e-health globally?=92 There is no conclusive answer to this = question.=20 There is no authoritative organization to oversee e-health activities = around the=20 world =96 or in developing countries in particular. The question as to = whether the=20 UN, the WHO, the World Bank or any other

Box 8.1 Summary of the report of the = WHO Global=20 Observatory for eHealth26

Key findings

1. Active involvement of the WHO in the = development of=20 generic e-health tools, and guidance in creating and implementing = e-health=20 services would be welcomed by Member States.

2. The need for guidance in a broad range of = e-health=20 areas was expressed in particular by countries that do not belong = to the=20 Organization for Economic Co-operation and Development = (OECD).

3. OECD countries did not express consistent = views of=20 their needs in e-health areas.

4. There is a need to raise awareness as to = what=20 e-health tools and services already exist at global and national=20 levels.

Proposed action

The WHO, in collaboration with public and = private sector=20 partners, should take action in the following key = areas:

1. Provision of generic tools. The = WHO should=20 facilitate the development of those generic e-health tools most = sought=20 after by its Member States, including tools for monitoring and = evaluation=20 of e-health services; drug registries; institutional = patient-centred=20 information systems that could be extended to include electronic = health=20 record systems; and directories of health care professionals and=20 institutions.

2. Access to existing tools. As a = parallel and=20 complementary action, electronic directories of existing e-health = tools=20 and services should be created, with an emphasis on open-source=20 solutions.

3. Facilitating knowledge exchange. = An=20 international knowledge exchange network to share practical = experiences on=20 the application and impact of e-health initiatives should be = built. This=20 would be Internet based and could be complemented by international = e-health conferences to facilitate networking.

4. Providing e-health information. = The WHO=20 should create a digital resource of e-health information to = support the=20 needs of Member States in key areas such as e-health policy, = strategy,=20 security and legal matters.

5. Education. The use of e-learning = programmes=20 for professional education should be promoted in the health = sciences, as=20 well as in ongoing professional development. Collaborations should = be=20 developed to generate databases of existing e-learning courses. = The WHO=20 should advocate the inclusion of e-health courses within = university=20 curricula.

organization should take the responsibility for = e-health=20 activities in developing countries remains unanswered. What makes = responding to=20 this question even harder is that it implies a number of other = questions:=20 whether this organization has the capacity to fulfil the expectations; = whether=20 it is willing to take this role; whether the role would be acceptable to = the=20 members of the international community. These are hard questions to = answer.=20 Without answers to these questions, it is difficult to formulate a = global=20 strategy for e-health.

The role of the WHO in promoting e-health globally has = to be=20 acknowledged. The WHO has recognized the need for e-health to address = health=20 issues in developing countries.25 It has also been instrumental in = forming=20 strategies, policies and standards for the utility of e-health. For = example, the=20 WHO Global Observatory for eHealth (GOe) was established to provide = Member=20 States with strategic information and guidance on effective practices, = policies=20 and standards in e-health.26 The GOe produced the first WHO Global = Survey on=20 e-health, eHealth Tools & Services: Needs of the Member = States, in=20 2005 (Box = 8.1).27

The WHO has formed an e-health standardization = coordination=20 group as a platform to promote stronger coordination among the key = players in=20 all technical areas of e-health standardization.28 The WHO has also initiated and = assisted a number=20 of e-health projects in different parts of the world. For example:

The = Telemedicine=20 Alliance was implemented with the collaboration of the European Union = and the=20 International Telecommunication Union.29

The WHO = Regional=20 Office for the Eastern Mediterranean (EMRO), in collaboration with the = Islamic=20 Republic of Iran Ministry of Health and Medical Education, organized the = Fourth=20 Regional e-Health Conference, which aimed to promote e-health.30

The WHO = has=20 initiated several e-health projects in African countries to address = health=20 issues, advance health and medical education, and raise awareness of = policy=20 makers in the use of ICT in health.31

A number = of e-health=20 projects have been undertaken in Sri Lanka (Table = 8.1).

However, there is little evidence to show the = success of any=20 of these activities. One of the most critical problems has been the = WHO=92s role=20 in funding e-health.

Strategies at international level

Strategies to promote e-health at international = level include=20 appointing an e-health governing body and linking international aid to=20 e-health.

As already mentioned, there is a critical need for a = global=20 governing body to oversee e-health activities. Setting up such an = organization=20 with appropriate legal and regulatory rights should be a priority. While = this=20 body would have authority relating to e-health activities across the = world, it=20 should also have the necessary financial capability to fund its = activities. An=20 organization with no financial capability will be doomed to failure. A = global=20 authority in e-health would be instrumental in defining matters such as=20 standards of practice, regulations and funding. Among other things, the=20 agenda

Table 8.1 E-health projects = in Sri=20 Lanka
Date	Project	Description
2001	Three-day course on basic and specialist = skills in=20 general surgery	The course was conducted by the Royal College = of=20 Surgeons of England and was delivered by distance education11 <= /TD>
2001	Feasibility study in partnership between the = WHO and the=20 Norwegian Centre for Telemedicine	This aimed to examine the potential for = telemedicine in=20 addressing problems of the health care sector in Sri Lanka12 <= /TD>
2003	Pilot e-health project funded by the WHO in=20 collaboration with the Ministry of Health of Sri Lanka	This low-cost, store-and-forward telemedicine = system was=20 designed to connect doctors in remote hospitals with specialists = for=20 consultation13 <= /TD>
2003	WHO-initiated pilot programme	This was designed to create a national = telemedicine=20 system, paying attention to wireless communication technologies in = telehealth14
2005	=91E-health Emergency Hospital=92 = project	The objectives of the project were to improve = recording=20 and reporting, improve communication via the Internet and email, = and=20 improve access to specialist advice in cases of emergency14

of such an organization should include education = and training=20 as a priority. Accreditation by this global e-health body would provide=20 much-needed recognition for e-health education to flourish. The = existence of a=20 global body would also assist the private sector to explore business=20 opportunities in this new field.

It is important that international development = assistance=20 schemes should be linked to the promotion of e-health. Currently, there = are=20 various overseas development funds that assist health and ICT projects. = Yet,=20 development assistance funds are not designed to help e-health. = International=20 donors must acknowledge that promotion of e-health is an integral part = of the=20 development of health in developing countries. Similarly, international = aid for=20 infrastructure development should be tied to the promotion of = e-health.

Conclusion

Although e-health has been generally accepted as a = useful=20 technique for improving access to health services in developing = countries, for=20 various reasons it has made very little progress. Policies at national = and=20 international level have not yet been able to facilitate e-health. At = the=20 national level, efforts must be made to raise awareness of policy = makers, health=20 personnel and business communities about the benefits of e-health. = Policy makers=20 must also have a more open-minded attitude towards e-health. At the=20 international level, there is a pressing need for a global authority to = oversee=20 e-health. This organization must have the financial and legal capacity = to=20 promote e-health. Overseas development assistance schemes must include = e-health=20 as an integral part of the development and promotion of health = generally.

References

1.=20 Al-Shorbaji N. WHO EMRO=92s approach for supporting e-health in the = Eastern=20 Mediterranean. East Mediterr Health J 2006; 12 = (Suppl=20 2): S238=9652.

2.=20 International Telecommunication Union. Telemedicine & eHealth = Directory,=20 2004. Available at:=20 www.itu.int/ITU-D/cyb/publications/2004/180ANN1E.pdf.

3.=20 E-Health Innovation Professionals Group. The Impact of e-Health and=20 Assistive Technologies on Health-care. 2005. Available at:=20 www.health-informatics.org/tehip/tehipstudy.PDF.

4.=20 Ray P, Androuchko L, Androuchko V. A comparative overview of e-health=20 development in developing and developed countries. 2006. Available at:=20 www.medetel.lu/download/2006/parallel_sessions/abstract/0406/Ray1.doc.

5.=20 Kumaranayake L, Mujinja P, Hongoro C, Mpembeni R. How do countries = regulate=20 health sector? Evidence from Tanzania and Zimbabwe. Health Policy = Plan=20 2000; 15: 357=9667.

6.=20 Islamic Development Bank. Importance of ICT to Economic = Development.=20 Available at: www.msctc.com.my/idb/2-3.htm.

7.=20 Wang EH. ICT and economic development in Taiwan: analysis of the = evidence.=20 Telecommunications Policy 1999; 23: = 235=9643.

8.=20 International Telecommunication Union. World Telecommunication/ICT=20 Development Report 2006: Measuring ICT for Social and Economic=20 Development. Available at:=20 www.itu.int/dms_pub/itu-d/opb/ind/D-IND-WTDR-2006-SUM-PDF-E.pdf.

9.=20 Islam KMB. National ICT Policies and Plans towards Poverty = Reduction:=20 Emerging Trends and Issues. Available at:=20 www.uneca.org/disd/events/accra/Poverty/ICT%20for%20Poverty%20Reduction-%= 20Paper%20by%20Baharul%20Islam.pdf.

10. World = Summit on the=20 Information Society. Plan of Action: Civil Society=92s = Priorities.=20 Available at: www.genderit.org/wsis/WSIS-CS-ActionPlan.doc.

11. United = Nations=20 Economic and Social Council. Economic and Social Commission for Asia and = the=20 Pacific. Report on the Current Economic Situation in the Region and = Related=20 Policy Issues. Available at:=20 www.unescap.org/EDC/English/Commissions/E63/E63_3E.pdf.

12. Kearns P. = An=20 International Overview of Trends in Policy for Information and = Communication=20 Technology in Education. Available at:=20 www.dest.gov.au/sectors/higher_education/publications_resources/summaries= _brochures/towards_the_connected_learning_society.htm.

13. World = Health=20 Organization Regional Office for the Eastern Mediterranean. Intercountry = Meeting=20 on Tele-medicine (Riyadh, Saudi Arabia, 7=969 February = 1999).Conclusions and=20 Recommendations. Available at:=20 www.emro.who.int/HIS/ehealth/Meetings-TelemedicineSAA1999.htm.

14. Drury P. = The=20 eHealth agenda for developing countries. World Hosp Health = Serv, 2005;=20 41: 38=9640.

15. = Metaxiotis K,=20 Ptochos D, Psarras J. E-health in the new millennium: a research and = practice=20 agenda Int J Electron Healthc 2004; 1: = 165=9675.

16. = Edirippulige S,=20 Marasinghe RB, Smith AC et al. Medical students=92 knowledge and = perceptions of=20 e-health: results of a study in Sri Lanka. In: MEDINFO 2007. = Amsterdam:=20 IOS Press, 2007: 1406=969.

17. = Parliamentary=20 Office of Science and Technology. ICT in Developing Countries.=20 Available at: www.parliament.uk/documents/upload/postpn261.pdf.

18. World = Bank.=20 2006 Information & Communications for Development (IC4D) =96 = Global Trends=20 and Policies. Available at: www.worldbank.org/ic4d.

19. = Edirippulige S,=20 Smith AC, Young J, Wootton R. Knowledge, perceptions and expectations of = nurses=20 in e-health: results of a survey in a children=92s hospital. J = Telemed=20 Telecare 2006; 12(Suppl 3): 35=968.

20. UNESCO = Secretariat.=20 Information and Communication Technologies in Development: A UNESCO=20 Perspective. Available at:=20 www.unesco.org/webworld/telematics/uncstd.htm.

21. Boucher = P.=20 Guidelines Public/Private Collaboration for ICT Development in = Health=20 Department of Knowledge Management and Sharing. Available at:=20 www.who.int/kms/initiatives/Guidelines.pdf.

22. United = Nations.=20 Fourth Annual Report of the Information and Communication = Technologies Task=20 Force. New York: United Nations, 2006.

23. Merchant = JA, Cook=20 TM, Missen CC. The Role of Information and Communications = Technology.=20 Available at: = www.who.int/bulletin/volumes/85/12/07-048975/en/print.html.

24. = Marasinghe RB,=20 Edirippulige S, Smith AC et al. A snapshot of e-health activities in Sri = Lanka.=20 J Telemed Telecare 2007; 13(Suppl 3): = 53=966.

25. World = Health=20 Organization. World Health Assembly Resolution on E-health = (WHA58.28,=20 May 2005). Available at: www.euro.who.int/telemed/20060713_1.

26. World = Health=20 Organization. Global Observatory for eHealth (GOe). Available = at:=20 www.who.int/kms/initiatives/ehealth/en/.

27. World = Health=20 Organization. eHealth Tools & Services: Needs of the Member = States.=20 Available at: = www.who.int/kms/initiatives/tools_and_services_final.pdf.

28. World = Health=20 Organization. eHealth Standardization Coordination Group. = Available at:=20 www.who.int/ehscg/en/.

29. World = Health=20 Organization Regional Office for Europe. Reports and Guidelines from = the=20 Telemedicine Alliance and Telemedicine Bridge Projects. Available = at:=20 www.euro.who.int/telemed/Publications/20060718_2.

30. World = Health=20 Organization Regional Office for the Eastern Mediterranean. Fourth = Regional=20 e-Health Conference: Building the Electronic Health Record = (Teheran,=20 Islamic Republic of Iran, 7=969 September 2004).Conclusions and=20 recommendations. Available at:=20 www.emro.who.int/his/ehealth/meetings-iran2004-recommendations.htm.

31. World = Health=20 Organization Regional Office for Africa. Knowledge Management in the = WHO=20 African Region: Strategic Directions. Available at:=20 afrolib.afro.who.int/RC/RC%2056/Doc_En/AFR-RC56-16%20Knowledge%20Manageme= nt%20-%20Final.pdf.

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SECTION 3
EDUCATIONAL

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9 Telemedicine in low-resource settings: = Experience with a=20 telemedicine service for HIV/AIDS care

Maria Zolfo, Verena Renggli, Olivier Koole = and Lut=20 Lynen

Introduction

In December 2003, the World Health Organization = (WHO) and the=20 Joint United Nations Programme on HIV/AIDS launched the =913 by 5=92 = initiative to=20 help low- and middle-income countries provide treatment to three million = people=20 living with HIV/AIDS. Although the target date of December 2005 was not = met, the=20 global efforts to scale up access to antiretroviral therapy (ART) have = brought=20 positive changes worldwide. At the end of 2006, more than two million = people=20 living with HIV were being treated with ART in low- and middle-income=20 countries.1

It has been an enormous challenge to introduce ART in = a safe and=20 effective way in resource-limited settings. The lack of human resources = and=20 clinical expertise has required approaches such as task shifting and=20 continuum-of-care models where non-HIV specialists, nurses and lay = providers all=20 play a role in HIV/AIDS care. The public health approach that was = proposed by=20 the WHO in 2003 has provided the tools necessary to deliver = decentralized HIV=20 care, including ART with limited resources.2

It is clear that supportive supervision and clinical = mentoring=20 is the cornerstone of this public health approach in most of the=20 resource-constrained clinical settings, where the health system is = already weak=20 and overwhelmed. Telemedicine (using the telephone, email, Internet or=20 videoconferencing) is one possible way of offering clinical mentoring. = We have=20 established a telemedicine service for physicians working in HIV/AIDS = services=20 in low-resource settings.

The HIV/AIDS TELEmedicine service

The Institute of Tropical Medicine in Antwerp (ITMA) = has run a=20 short course on ART (SCART) every summer since 2003. The course provides = three=20 weeks of training on ART and clinical management of HIV infection for = more than=20 40 physicians from resource-poor countries. After = completing=20 the course, a hybrid web/email forum is offered to the participants to = support=20 their decision-making and assist in the management of difficult HIV/AIDS = cases=20 in their daily clinical practice (Figure 9.1).3

The patient=92s history, physical examination, = laboratory findings=20 and questions to be answered are sent to a network of HIV/AIDS = specialists using=20 a discussion forum accessed through the TELEmedicine website (Figure 9.2). = All=20 postings submitted to this discussion forum are stored in a database and = available for consultation. An internal email account is also available = for=20 direct contact between members, facilitating the exchange of recent = literature,=20 policy documents and interaction between sites. In addition, a system of = email=20 warning messages can be used to give early notice when a new posting is=20 available on the discussion forum.

The TELEmedicine website contains interesting clinical = cases and=20 answers to common questions. This information can be consulted through a = search=20 function for continuing medical education (CME). Policy documents, = guidelines=20 and supporting material on HIV/AIDS care in low-resource settings and = links to=20 other important web-sites are also accessible.4,5 The = website=20 conforms with the Health On the Net Foundation Code of Conduct.6 This = code is=20 designed to improve the reliability of health information on the web. It = defines=20 a set of rules for website developers to ensure that readers always know = the=20 source and the purpose of the information that they are reading.

Service usage

Between April 2003 and March 2007, the TELEmedicine = service=20 received 642 second-opinion requests, from more than 35 = resource-constrained=20 countries. Three-quarters of the teleconsultations concerned management = of=20 complex medical problems in a specific patient and one-quarter were = questions in=20 the field of organization of health services for HIV prevention, = treatment and=20 care, vaccination programmes and guidelines.

In the first three years of activity (April = 2003=96March 2006),=20 there were 491 queries. Of these, 47% (n =3D 230) were related = to the=20 general use of antiretrovirals, side effects, second-line regimens, = prevention=20 of mother-to-child transmission (PMTCT), immune reconstitution syndrome, = TB/HIV=20 and management of other co-infections during ART; 40% (n =3D = 197) were=20 related to the diagnosis and treatment of specific opportunistic = infections and=20 13% (n =3D 64) to general topics such as the organization of = health=20 services for AIDS care, directly observed TB therapy, vaccination = programmes and=20 guidelines (Figure=20 9.3).

During the first three years of TELEmedicine activity, = we=20 noticed a significant increase in the proportion of questions related to = organizational issues of HIV programmes: from 8% during the first year = to 27%=20 during the third year (P < 0.001). The opposite occurred for = questions on=20 general use of antiretrovirals (from 14% to 5%), management of side = effects=20 (from 12% to 5%) and management of specific opportunistic infections = (from 44%=20 to 30%); these differences were significant (P < 0.05).

There was a clear reduction in the numbers of = questions on=20 general use and side effects of antiretrovirals and a significant = increase in=20 questions concerning the

3DImage=20

Figure 9.1 TELEmedicine website3

3DImage=20

Figure 9.2 TELEmedicine website = discussion=20 forum

3DImage=20

Figure 9.3 Telemedicine referrals = (first three=20 years of service). ARVs, antiretrovirals; IRIS, immune reconstitution=20 inflammatory syndrome; OIs, opportunistic infections; TB, tuberculosis; = PMTCT.=20 prevention of mother-to-child transmission

organizational issues of ART programmes. This is = related to=20 the maturing of the HIV/AIDS programmes. Thus, in the last two years, we = have=20 received many questions about ART roll-out: how to increase access to = treatment=20 and care, how to implement PMTCT services in ART clinics, and how to = extend care=20 to paediatric HIV cases. These questions do not arise in the early = stages, when=20 the burden of first-line access to HIV care is the main problem. It is = also=20 clear that management of opportunistic infections remains a challenge, = and=20 training programmes should not neglect this aspect of HIV care.7

User satisfaction

A survey was conducted in 2006 to evaluate = clinicians=92=20 perception of the TELEmedicine service. The members were divided into = =91active=20 users=92 (i.e. clinicians who participated in the discussion forum) and = =91passive=20 users=92 (i.e. clinicians who consulted the TELEmedicine forum but did = not post=20 clinical cases and/or questions there).

There was a response rate of 53% among active users = (18/34).=20 Among these respondents, the service was judged to have been useful in=20 influencing the management of the patients in 100% of cases, and 67% of = the=20 users perceived that the advice was useful in more than 75% of cases. = The=20 service was beneficial for the establishment of the diagnosis (78%), for = the=20 referring clinician=92s education (55%) and for reassurance (39%).8

Computer skills

Lack of access to information remains one of the = major=20 barriers to the practice of evidence-based medicine in low-resource = settings.=20 The problems include limited access to computer facilities, to = literature=20 databases and to CME programmes.

At the end of the short courses in 2004 and 2005, we = assessed=20 physicians=92 access to the web and their abilities to use computers = while working=20 in the field. Out of the total of 84 trained physicians, who were mainly = African=20 and Asian nationals working for international organizations or for the = ministry=20 of health, 75 completed the questionnaires. While = 11% of the=20 physicians stated that they did not have access to the web, almost all = of them=20 (74/75) said that they had their own email account. Of the respondents, = 69%=20 preferred to access the Internet in the evening (17:00=96midnight). A = connection=20 speed of at least 28.8 kbit/s was available to 40% of them. For 83%, the = operating system they used was Windows 2000/XP, 93% had a CD reader and = 63% had=20 a sound card on their computers. Two-thirds of the users reported that = they were=20 able to download files and to use software such as Acrobat, Excel, = PowerPoint,=20 WinZip and Word.

Online course

Although web access and information and = communication=20 technology (ICT) ability and use remain limited in low-resource = settings, our=20 selected group of physicians who attended the short course showed a good = level=20 of basic informatics knowledge, ability to use computers and access to = the=20 Internet.9 This = type of=20 information helped us to plan the delivery of online modules through the = website=20 for CME purposes and to start the conversion of the face-to-face course = to an=20 online training modality (eSCART).

The eSCART content is structured into 13 different = modules and=20 uses a problem-based learning approach with clinical cases, tutorials,=20 additional readings and self-assessments. At a workload of 4=965 study = hours per=20 week, the 3-week face-to-face course requires a minimum of 3 months=92 = online=20 training. To expand the availability of the eSCART course, we intend to = work=20 with appropriate international organizations and offer adaptations for = HIV/AIDS=20 programmes in low-resource settings.

Other telemedicine approaches

Consultations

Some HIV/AIDS programmes in low-resource settings = have=20 developed a consultation system that allows newly trained providers to = ask=20 questions of an expert through direct telephone calls, email and call = centres.=20 Telephone contact is usually set up so that health care workers and = patients can=20 make a toll-free or low-cost phone call to a central location.

Call centre in Uganda

The AIDS Treatment Information Centre at the = Infectious=20 Disease Institute (IDI) of Makerere University in Kampala hosts a call = centre=20 that responds to providers=92 treatment questions. The centre operates = during=20 normal office hours.10 It = is staffed=20 by clinical pharmacists, who are supported by the IDI faculty. The call = centre=20 automatically records the caller=92s telephone number, and the staff = return the=20 call at no cost to the caller. The centre automatically develops a = database of=20 the most frequently asked questions.11

Satellife (HealthNet)

This is an international not-for-profit organization = that uses=20 the Internet for health information purposes in the developing world.12 The = organization aims to improve the communication and = exchange of=20 information in the fields of public health, medicine and the = environment. There=20 are global discussion groups (e.g. in nutrition, essential drugs, = paediatric=20 management and nursing). Using a low-Earth-orbit satellite and telephone = lines=20 for telecommunication, the organization provides email access in 140 = countries,=20 to a total of about 10 000 health care workers. Special emphasis is = placed on=20 areas of the world where access is limited by poor communications, = economic=20 conditions or disasters. Where adequate telecommunication links exist, = Satellife=20 and other organizations provide higher-capacity email and Internet = connections.=20 These allow the transmission of email attachments such as image files. = The=20 patient=92s findings can be described in an email message, and digital = photographs=20 of the patient and their investigations, such as electrocardiograms and = X-ray=20 films, can then be attached. This =91store-and-forward=92 telemedicine = does not=20 allow real-time interaction, but it permits specialist support in the = management=20 of difficult cases (see Chapter 19).

Case conferences

Another way to mentor health care workers is through = case=20 conferences, i.e. regular meetings to discuss complex problems in HIV = care and=20 to provide updates on practices or guidelines. For example, telephone=20 conferences are used by the Heineken Company for mentoring its health = care=20 workers. In the period October 2001 to December 2003, the company had 10 = health=20 care workers operating in 5 different African countries. A total of 268 = problems=20 were raised during 45 telephone conferences. There were 79 questions = (29%) about=20 ART, 53 (20%) about the diagnosis and treatment of opportunistic = infection, 43=20 (16%) about antiretroviral toxicity, 40 (15%) about care organization = and=20 policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about = biological=20 parameters. The level of satisfaction among local company physicians was = 65% for=20 logistics, 89% for scientific relevance, 84% for applicability of advice = and 85%=20 overall. The most common complaints concerned the poor quality of the = telephone=20 connection and language problems for francophone participants. This = showed that=20 database-supported telephone conferencing could be useful for mentoring = company=20 health care workers in their routine care of HIV-infected workers and = family=20 members.13

Twinning

An established relationship between two institutions = to share=20 expertise is referred to as twinning. Ideally, these are long-term = partnerships=20 (at least three years), with clear, common objectives that serve as a = basis for=20 exchanging expertise and experience for the benefit of both = institutions. A=20 twinning broker, such as the Twinning Center,14 = develops and=20 supports twinning partnerships. The Twinning Center is also exploring = mechanisms=20 to support collaboration between institutions in resource-constrained=20 settings.11

Another example of this approach is the collaboration = between=20 the Moi University Faculty of Health Sciences in Kenya and both the = Indiana=20 University School of Medicine and the Brown University School of = Medicine in the=20 USA.

Twinning increases resources for individual = institutions by=20 facilitating a flow of funds and an exchange of information and = expertise from=20 one institution to the other. There is, however, a = limit to=20 the number of available twinning programmes, and trainers from foreign=20 institutions are not always knowledgeable about local conditions, = language or=20 policy.15

Other web-based collaboration and = telemedicine=20 systems

There are a number of other web-based collaboration = and=20 telemedicine systems, not restricted to the field of HIV.

AIDSPortal

This is an Internet portal that provides tools to = support=20 global collaboration and knowledge sharing among new and existing = networks of=20 people responding to the AIDS epidemic.16 = AIDSPortal=20 offers: networking (members can access a directory of people and = organizations=20 to locate others interested in similar problems or working in a = particular=20 place); policy dialogue (the most up-to-date information on policy = initiatives=20 and international processes is easily accessible through AIDSPortal, and = people=20 can share information about their engagement); country-led management=20 (supporting constructive dialogue between national responses and = experiences and=20 international processes); and access to information (AIDSPortal = facilitates=20 access to information given the time and resource constraints facing=20 organizations responding to HIV and AIDS).

Community-based HIV treatment programme in=20 Haiti

Partners In Health and Zanmi Lasante launched a=20 community-based HIV treatment programme in Haiti=92s impoverished = central plateau.=20 It is a web-based medical record system linking remote areas in rural = Haiti. It=20 is used to track clinical outcomes, laboratory tests, drug supplies,=20 communications, data analysis and drug supply management. Decision = support is=20 particularly useful for interpreting laboratory results. Technicians at = two=20 clinical sites enter patients=92 CD4 cell counts. Each night, a program = checks for=20 patients with low CD4 counts who are not receiving the appropriate drug = regimen.=20 A warning email message is sent to all 20 Zanmi Lasante clinicians and = contains=20 a link to the electronic medical records of patients who require = additional=20 treatment. Reminders can also be generated for patients who require = extra drugs=20 or investigations.17

Cell-Life

This is a platform for communication, information = and=20 logistical support to manage HIV/AIDS patients, enabling close = monitoring of ART=20 adherence and providing support to health care workers visiting AIDS = patients in=20 remote areas. The system supports communications technology, such as = mobile=20 phones and the Internet.18,19

RAFT (R=E9seau en Afrique Francophone pour la=20 T=E9l=E9medecine)

The RAFT project permits remote collaboration, case = discussion=20 and data sharing over low-bandwidth networks between the Geneva = University=20 Hospitals and 10 French-speaking African countries.20,21 The = core=20 activity of the RAFT is the webcasting of interactive courses. Other = activities=20 include videoconferences, teleconsultations based on = the iPath=20 system, collaborative knowledge base development, support for medical = laboratory=20 quality control, and the evaluation of the use of telemedicine in rural = areas=20 (via satellite connections) in the context of multisectorial = development. The=20 project uses Linux and other open source software.

iPath

This is Internet-based software for the exchange of = medical=20 knowledge, distance consultations, group discussions and distance = teaching in=20 medicine and allows image sharing in pathology, radiology and = dermatology.22,23 It = is being=20 used in Africa, Asia and the Pacific. It is built with open source = software,=20 which is available free at http://www.sourceforge.net/. More=20 than 200 discussion groups use the iPath system.

Conclusions

More than two million people infected with HIV are = now=20 receiving ART in middle-and low-income countries. However, this has = created=20 extraordinary demands on health care workers in areas where health = systems were=20 already weak and overwhelmed. Thus, there are several problems in = scaling up=20 treatment programmes. A number of approaches are being tried, including=20 mobilization of national and private partners, decentralization of = HIV/AIDS=20 services, and training and mentoring of health care workers.

It is evident that training and supervision are = critical=20 factors. Over the past few years, private donors and large = organizations, such=20 as the President=92s Emergency Plan for AIDS Relief and the Global Fund, = have=20 begun to be involved in pre-service training and mentoring of health = care=20 workers dealing with HIV/AIDS care in low-resource settings. Some = developing=20 countries have established collaborations with external partners to = access=20 training curricula or shape existing didactic material into a new model = of=20 teaching (training of trainers, onsite refresher courses, CME and = distance=20 learning), and some of the programmes have even expanded the range of = support,=20 offering attachments or onsite mentoring.

Telemedicine is one of the approaches to mentoring = health care=20 workers in low-resource settings, even though exhaustive data about its=20 effectiveness are not yet available. In many settings, connectivity and = computer=20 literacy are still major limitations. In our experience, the opportunity = for=20 continued dialogue with physicians in the field has been valuable. It = has=20 allowed the identification of HIV/AIDS knowledge gaps and provided = answers to=20 some critical questions. Decisions on how to best support programmes on = HIV/AIDS=20 care in low-resource settings should really be made after taking into = account=20 the questions raised in the field.

The Institute of Tropical Medicine in Antwerp offers = both=20 face-to-face training courses and online training in ART. The = TELEmedicine=20 website also supports the management of difficult HIV/AIDS clinical = cases via a=20 discussion forum, where a network of international specialists is = available to=20 give second opinion advice. This is just one example of mentoring health = care=20 workers and providing direct support in the management of HIV/AIDS = clinical=20 cases. We believe that by giving clinicians the opportunity to=20 access support and clinical mentoring, it is possible to lower the = threshold for=20 launching ART programmes. In addition, updating staff through CME helps = to=20 maintain quality in ART programmes, even in resource-limited = settings.

Acknowledgements

This work was supported by the Belgian Directory = General of=20 Development Cooperation. We thank Vera Van Boxel and Joris Menten for = the data=20 analysis and Carlos Kiyan for offering advice.

References

1.=20 World Health Organization. Towards Universal Access: Scaling up = Priority=20 HIV/AIDS Interventions in the Health Sector. Geneva: WHO, 2007. = Available=20 at: = www.who.int/hiv/mediacentre/univeral_access_progress_report_en.pdf.

2.=20 World Health Organization. Antiretroviral Therapy for HIV Infection = in=20 Adults and Adolescents: Recommendations for a Public Health = Approach.=20 Geneva: WHO, 2006. Available at:=20 www.who.int/hiv/pub/guidelines/artadultguidelines.pdf.

3.=20 TELEmedicine website. Available at: telemedicine.itg.be.

4.=20 Zolfo M, Lynen L, Dierckx J, Colebunders R. Remote consultations and = HIV/AIDS=20 continuing education in low-resource settings. Int J Med Inform = 2006;=20 75: 633=967.

5.=20 Zolfo M, Arnould L, Huyst V, Lynen L. Telemedicine for HIV/AIDS care in = low=20 resource settings. Stud Health Technol Inform 2005;=20 114: 18=9622.

6.=20 Health On the Net Foundation. Quality and Trustworthiness of the = Medical and=20 Health Web. Available at: www.hon.ch/visitor.html.

7.=20 Zolfo M, Koole O, Renggli V et al. Online consultations for HIV/AIDS = care in=20 resource-limited settings. In: Proceedings of the 11th Congress of = the=20 International Society for Telemedicine, 26=9629 November 2006, Cape = Town,=20 South Africa.

8.=20 Zolfo M, Renggli V, Koole O et al. Telemedicine survey on users=92 = satisfaction.=20 In: Proceedings of the 11th Congress of the International Society = for=20 Telemedicine, 26=9629 November 2006, Cape Town, South Africa.

9.=20 Zolfo M, Lynen L, Renggli V et al. Computer skills and digital divide = for=20 HIV/AIDS doctors in low resource settings. In: Proceedings of Med-e-Tel, = 5=967=20 April 2006, Luxexpo, Luxembourg.

10. AIDS = Treatment=20 Information Centre Website. Available at:=20 www.idi.ac.ug/index.php?m=3Dmenu&i=3D170.

11. World = Health=20 Organization. WHO Recommendations for Clinical Mentoring to Support = Scale-up=20 of HIV Care, Antiretroviral Therapy and Prevention in Resource = Constrained=20 Settings. Geneva: WHO, 2006. Available at:=20 www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf.

12. = AED-SATELLIFE=20 website. Available at: www.healthnet.org.

13. = Clevenbergh P, Van=20 der Borght SF, van Cranenburgh K et al. Database-supported = teleconferencing: an=20 additional clinical mentoring tool to assist a multinational company = HIV/AIDS=20 treatment program in Africa. HIV Clin Trials 2006; = 7:=20 255=9662.

14. HIV/AIDS = Twinning=20 Center website. Available at: www.twinningagainstaids.org.

15. McCarthy = EA,=20 O=92Brien ME, Rodriguez WR. Training and HIV-treatment scale-up: = establishing an=20 implementation research agenda. PLoS Med 2006; = 3:=20 e304.

16. = AIDSPortal website.=20 Available at: www.aidsportal.org.

17. Jazayeri = D, Farmer=20 P, Nevil P et al. An Electronic Medical Record system to support HIV = treatment=20 in rural Haiti. AMIA Annu Symp Proc 2003: 878.

18. Cell-Life = website.=20 Available at: www.cell-life.org.

19. Skinner = D, Rivette=20 U, Bloomberg C. Evaluation of use of cellphones to aid compliance with = drug=20 therapy for HIV patients. AIDS Care 2007; 19:=20 605=967.

20. AFT = website.=20 Available at: raft.hcuge.ch.

21. = Geissbuhler A,=20 Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing = medical=20 education and tele-consultations over the Internet in French-speaking = Africa.=20 Int J Med Inform 2007; 76: 351=966.

22. iPath = website.=20 Available at: telemed.ipath.ch/ipath.

23. Brauchli = K,=20 Oberholzer M. The iPath telemedicine platform. J Telemed = Telecare 2005;=20 11(Suppl 2): 3=967.

10 Medical Missions for Children: A global = telemedicine and=20 teaching network

Philip O Ozuah and Marina = Reznik

Introduction

Advances in information and communication technology = (ICT)=20 have provided new ways of delivering health care.1 The = World=20 Health Organization (WHO) has recognized the role of =91health = telematics=92 in=20 improving access to medical and health care, health education, global = health=20 promotion, training of health personnel and the management of emergency=20 situations.2 This = is=20 particularly relevant in developing countries, where there are often = growing=20 health disparities, and where children are particularly affected by = inequalities=20 of access.

Telemedicine has become increasingly popular in both=20 industrialized and developing countries.1 In = developing=20 nations, telemedicine has important effects on many aspects of health = systems.3 It = has the=20 potential to improve health care by removing time and distance barriers, = providing medical education and medical care, and optimizing the use of = the=20 limited health services available in these under-served communities.4

There have been many reports suggesting the potential = advantages=20 and benefits of telemedicine as a useful technique for delivering health = care in=20 the developing world.5=968 = However, few=20 authors have described the actual clinical experience of using = telemedicine=20 there.9=9613 = The reported=20 use of telemedicine for children in developing countries is even more = limited.14=9617 = Medical=20 Missions for Children (MMC) is a US not-for-profit organization that = operates a=20 global videoconferencing network. It delivers expertise from medical = specialists=20 and technicians based in hospitals in the USA to children needing care = in=20 developing countries by using telemedicine.18

Medical Missions for Children

The goal of MMC is to improve health care for = children in=20 medically under-served communities by using telemedicine. It has the = following=20 aims:18

1. To provide medical diagnoses and treatment via = telemedicine=20 to children and mothers in under-served communities around the = world.

2. To facilitate medical knowledge transfer from those = who have=20 it to those who need it using the latest in communication = technology.

3. To support applied medical research utilizing=20 state-of-the-art communications infrastructure.

MMC works with a network of 27 American hospitals, = who mentor=20 participating hospitals in under-served countries.18 It provides videoconferencing = equipment for the=20 hospitals in the developing world, as well as satellite time for the=20 communication. Videoconferencing equipment (donated by Polycom) includes = ViewStation HXD 9000, ViewStation VSX 7000 and HDX equipment, which = communicates=20 at band-widths from 384 kbit/s to 4 Mbit/s. Physicians from the = mentoring=20 hospitals volunteer their time and expertise to participate via = videoconference=20 in remote examinations of patients, consultations about diagnosis and = treatment,=20 and education about new procedures, drugs and medical equipment.

History

MMC was founded in March 1999 by Peg and Frank Brady = at St=20 Joseph=92s Children=92s Hospital in Paterson, New Jersey, as a way of = screening ill=20 children from developing countries prior to doctors travelling to treat = them.=20 After eight years of operation, MMC serves children in over 100 = countries=20 throughout Latin America, the Caribbean, Europe, Africa, Asia, the = Pacific and=20 the Middle East. At least three patient consultations or diagnostic = sessions are=20 held by videoconference each day, with 1000=961200 direct consultations = conducted=20 every year. Since its inception, MMC has provided diagnostic = consultations to=20 almost 25 000 children, using the expertise of more than 600 physicians = from 27=20 mentoring hospitals via telemedical support.

Programmes

MMC=92s work is accomplished through five = programmes.

1. Telemedicine Outreach = Programme

MMC operates a distance medicine network in more = than 100=20 countries, called the Telemedicine Outreach Programme. This programme, a = partnership with the World Bank, allows physicians to be electronically = linked=20 to patients in remote locations. MMC maintains a network of 27 mentoring = hospitals in the USA and Europe that participate in the programme.18

2. Medical Broadcasting = Channel

The Medical Broadcasting Channel (MBC) was launched = in=20 November 2005. It was developed as a means of helping physicians and = other=20 health care professionals to stay abreast of the latest developments in = the=20 medical field. High-quality, up-to-date medical education is delivered = to=20 physicians and allied health care workers around the world by satellite=20 broadcasting and Internet streaming. The Intelsat 903 satellite is used = to=20 broadcast medical content to an area that encompasses 9 million = physicians, 14=20 million nurses, 5 million health care workers, 89 000 hospitals, and 16 = 000=20 universities and medical schools.18

MBC is also available via the Internet2, the = high-speed research=20 version of the Internet. This network can support the transmission of = TV-quality=20 video and is available in 88 countries around the world.19 = The network=20 is available to more than 300 000 institutions, including universities,=20 government agencies, hospitals, medical schools, corporations and = research=20 facilities.

Eight daily seminars on different medical topics = ranging from=20 paediatrics to geriatrics are transmitted three times a day via = satellite and=20 the Internet. By providing and disseminating this latest medical = information,=20 MMC helps to increase the level of expertise in each participating = hospital, as=20 well as alleviating the disparity of care between industrialized nations = and the=20 developing world.

3. Global Video Library of = Medicine

The Global Video Library of Medicine (GVLM) provides = health=20 care workers around the world with free access to an archive of more 25 = 000=20 hours of medical video. GVLM is the digital repository of thousands of=20 video-based medical lectures, news programmes, symposia and training = sessions,=20 all of which are available to health care providers throughout the = world. It=20 provides a reliable source of clinical and medical research content via = the=20 public Internet.18 It is available to health care = professionals as=20 well as the general public. Its Video-on-Demand capability allows = researchers to=20 search for and retrieve medical content. GVLM also serves as the content = source=20 for MBC.

4. Giggles Children=92s = Theatre

The Giggles Children=92s Theatre performs three = times each week=20 to bring the healing powers of laughter and entertainment to = hospitalized=20 children in the city of Paterson, New Jersey (Figure 10.1). = From the=20 comfort of the Giggles Theatre, children are able to travel the globe on = interactive virtual field trips that include swimming with sharks, = visiting zoos=20 and museums, and exploring rainforests.

The theatre provides a short escape from the fear and = monotony=20 that often accompany a hospital stay. Giggles presentations are also = delivered=20 via closed circuit television to the bedside of children too ill to come = to the=20 theatre and are broadcast via satellite and Internet2 to other = children=92s=20 hospitals around the world.18

5. MMC-produced television = shows

The belief in creating knowledgeable patients who = can work as=20 a team with the physician to manage their illnesses led MMC to produce = three=20 television programmes for the Public Broadcasting System and MBC. The = programmes=20 educate individuals about health problems that could affect them and = their=20 families. The programmes are:18

Plain = Talk about=20 Health, which was designed to take the medical jargon out of = important=20 conversations about health.

= Tomorrow=92s=20 Medicine Today, which includes interviews with the directors of the = 27=20 institutes of the US National Institutes of Health (NIH) and researchers = from=20 around the world.

3DImage=20

Figure 10.1 A Giggles Children=92s = Theatre=20 presentation of Aesop=92s Fables

Take = Care,=20 which presents a patient describing his symptoms and the subsequent = review and=20 diagnosis by specialists.

Case report

The first child helped by MMC, Yordano, was an = 11-year-old boy=20 from rural Panama who was born with a cranial deformity resulting in the = absence=20 of one eye, difficulty in swallowing and learning difficulties. Yordano = comes=20 from a family of six. His father is a painter and his mother is a = seamstress. He=20 has an 18-year-old brother, a 5-year-old brother and a healthy twin = brother.=20 Yordano was the first child to use the MMC telemedicine network. He was = examined=20 by the physicians at St Joseph=92s Children=92s Hospital in New Jersey, = and it was=20 decided that he could be helped. A computer model of his head was = created with=20 the help of interactive telemedicine to collect the measurements. Then, = using a=20 computer, physicians designed titanium implants to correct his = deformity. A=20 physical model was made to confirm that all the parts fitted properly. = Yordano=92s=20 doctors in Panama were involved with the preparation. However, it was = decided=20 that his surgery should be performed at St Joseph=92s. Yordano and his = mother=20 arrived in the USA in November 2001 for the initial surgery. = Subsequently,=20 Yordano had 11 surgical procedures performed at St Joseph=92s to = reconstruct his=20 skull and jaw, to create an eye socket for a prosthetic eye and to = receive a new=20 titanium jaw (Figures=20 10.2=9610.4).=20 After this surgery was completed, educational sessions were held by the surgeons from the USA, who used the MMC network = to review=20 the procedure with 50 physicians from Panama. The plan is for Yordano to = have=20 one more operation in Panama to align his jaw. He is now 17 years old = and doing=20 well.

3DImage=20

Figure 10.2 Yordano with Dr Hillel = Ephros

3DImage=20

Figure 10.3 Yordano, post = surgery

3DImage=20

Figure 10.4 Yordano, seven years = after the=20 first operation

MMC and the Children=92s Hospital at = Montefiore

The Children=92s Hospital at Montefiore in the = Bronx, New York,=20 acts as a mentoring hospital for the University College Hospital in = Ibadan,=20 Nigeria. The object is to provide health education and better access to = medical=20 care for children in Nigeria. The International Center for Child Health = at the=20 Children=92s Hospital at Montefiore (CHAM) houses telemedicine equipment = to=20 facilitate encounters between CHAM staff and Nigerian medical = professionals,=20 providing a forum for medical information exchange in the form of = training=20 sessions, seminars, symposiums and consultations via = videoconferencing.

Working in partnership with the MMC, CHAM is = sponsoring the=20 College of Medicine at University College Hospital in Ibadan. MMC has = provided=20 the telemedicine equipment for the hospital in Nigeria. A curriculum of = the=20 hospital=92s educational needs and interests is being developed by = medical staff=20 in Nigeria in collaboration with CHAM faculty members. An agreement = between MMC=20 and the World Bank allows CHAM to connect with the Medical Missions site = (via=20 three ISDN lines) and access the World Bank satellite to reach the = College of=20 Medicine via Ibadan=92s satellite dish. The World Bank pays for the = satellite=20 time.

Our Nigerian partner has responsibility only for = providing space=20 for the telemedicine equipment and administrative support to ensure the = quality=20 and sustainability of the programme. They also = provide an=20 appropriate mechanism for assessing and discussing the medical and = educational=20 needs of Nigeria, to ensure that the programme contributes to the = enhancement of=20 paediatric health care.

Conclusion

There are many potential benefits of using = telemedicine to=20 deliver health care in the developing world.7=969 = However, there=20 are few reports that describe the use of telemedicine for children in = developing=20 countries. MMC, a non-profit-making organization, has a well-established = telemedicine network between mentoring hospitals in the USA and = hospitals in=20 developing nations. Since its inception, the programme has provided = direct=20 medical consultation and services to some 25 000 children in developing=20 countries.

References

1.=20 Wootton R, Craig J, Patterson V, eds. Introduction to = Telemedicine, 2nd=20 edn. London: Royal Society of Medicine Press, 2006.

2.=20 World Health Organization. Health-for-all Policy for the = Twenty-First=20 Century (Document EB101/INF. DOC./9). Geneva: WHO, 1998.

3.=20 Edworthy SM. Telemedicine in developing countries. BMJ 2001;=20 323: 524=965.

4.=20 Zhao Y, Nakajima I, Juzoji H. On-site investigation of the early phase = of Bhutan=20 Health Telematics Project. J Med Syst 2002; = 26:=20 67=9677.

5.=20 Einterz EM. Telemedicine in Africa: potential, problems, priorities.=20 CMAJ 2001; 165: 780=961.

6.=20 Fraser HS, McGrath SJ. Information technology and telemedicine in = sub-Saharan=20 Africa. BMJ 2000; 321: 465=966.

7.=20 Groves T. SatelLife: getting relevant information to the developing = world.=20 BMJ 1996; 313: 1606=969.

8.=20 Kastania AN. Telemedicine models for primary care. Stud Health = Technol=20 Inform 2004; 104: 89=9698.

9.=20 Wootton R. The possible use of telemedicine in developing countries. = J=20 Telemed Telecare 1997; 3: 23=966.

10. Wootton = R.=20 Telemedicine and developing countries =96 successful implementation will = require a=20 shared approach. J Telemed Telecare 2001; = 7(Suppl 1):=20 1=966.

11. Vassallo = DJ,=20 Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine = system=20 in three developing countries. J Telemed Telecare 2001;=20 7(Suppl 1): 56=968.

12. = Patterson V, Hoque=20 F, Vassallo D et al. Store-and-forward teleneurology in developing = countries.=20 J Telemed Telecare 2001; 7(Suppl 1): = 52=963.

13. Latifi = R, Muja S,=20 Bekteshi F, Merrell RC. The role of telemedicine and information = technology in=20 the redevelopment of medical systems: the case of Kosova. Telemed J = E=20 Health 2006; 12: 332=9640.

14. Lee S, = Broderick=20 TJ, Haynes J et al. The role of low-bandwidth telemedicine in surgical=20 prescreening. J Pediatr Surg 2003; 38: = 1281=963.

15. Person = DA, Hedson=20 JS, Gunawardane KJ. Telemedicine success in the United States Associated = Pacific=20 Islands (USAPI): two illustrative cases. Telemed J E Health = 2003;=20 9: 95=96101.

16. Graham = LE,=20 Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way ahead for = medicine in the=20 developing world. Trop Doct 2003; 33: = 36=968.

17. Qaddoumi = I,=20 Mansour A, Musharbash A et al. Impact of telemedicine on pediatric=20 neuro-oncology in a developing country: the Jordanian=96Canadian = experience.=20 Pediatr Blood Cancer 2007; 48: 39=9643.

18. Medical = Missions=20 for Children. Global Telemedicine and Teaching Network. = Available at:=20 www.mmissions.org/index.html.

19. Medical = Missions=20 for Children. List of Countries Aided by MMC=92s Telemedicine Outreach = Program.=20 Available at: www.mmissions.org/top/countries.html.

11 Telementoring in India: Experience with = endocrine=20 surgery

Saroj K Mishra, Puthen V Pradeep and Anjali=20 Mishra

Introduction

Telementoring =96 mentoring through the use of = telecommunication=20 =96 provides access to more experienced staff. This is an application of = tele-education in general. In surgery, telementoring allows a remotely = located=20 surgeon to obtain the help of centrally located, more experienced = surgeons in=20 performing complicated procedures. This may occur before, or even = during,=20 surgery, when expert advice can improve intraoperative decision = making.

Intraoperative assistance has been described by = several=20 authors.1,2 At = the Sanjay=20 Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) in Lucknow, = we have=20 developed telementoring further, so that a mentor=92s input is = continuously=20 provided for the overall clinical care of the patient, to assist in = diagnosis,=20 preoperative treatment planning and postoperative care.3 = Telementoring=20 has been incorporated into the training and teaching programme of the = Department=20 of Endocrine Surgery at the SGPGIMS. This department is one of only two = in India=20 that provide curriculum-based training in this relatively new = subspecialty.=20 Hence, the short-course training given in house to general surgeons is = further=20 consolidated with telementoring. This model may be relevant to other = developing=20 countries where there is a shortage of staff in certain = subspecialties.4,5

Telemedicine in India

Public health care in India is primarily a = responsibility of=20 the state or province. The health system has a three-tiered structure: = the=20 primary health care centres cover a group of villages, secondary level = health=20 centres are at district level and medical colleges, located in big = cities,=20 provide tertiary care. Private sector hospitals account for almost 60% = of health=20 care.

Both government and private agencies have begun = telemedicine=20 projects. Government agencies that support these activities are the = Indian Space=20 Research Organization (ISRO), the Department of Information Technology, = the=20 Ministry of Communications and IT, the Department = of Science=20 and Technology, and the Ministry of Defence. In addition, self-funded = activities=20 are being carried out by various corporate hospitals. A few mobile = telemedicine=20 units using satellite connectivity provided by ISRO have been introduced = for=20 community ophthalmology care. At present, ISRO=92s telemedicine network = consists=20 of about 200 nodes spread across the country.

The Department of Information Technology has produced = guidelines=20 and standards for the practice of telemedicine in India, which are aimed = at=20 enhancing interoperability among the various telemedicine systems being = set up=20 in the country.6 This = document=20 aims to streamline the establishment of telemedicine centres and to = standardize=20 services available from different telemedicine centres. In addition to=20 suggesting standards for various equipments needed for setting up = telemedicine=20 centre, it also provides guidelines for conducting telemedicine=20 interactions.

The Ministry of Health and Family Welfare has recently = launched=20 two national projects. The first is oncoNET India, which will connect 25 = regional cancer centres with four peripheral medical colleges/hospitals = each,=20 creating a network of about 100 telemedicine nodes exclusively for = cancer care.=20 The second is the Integrated Disease Surveillance Project, in which all = the=20 district hospitals in India will be networked with regional medical = colleges.=20 The object is to improve surveillance of diseases of public health = importance=20 and to deliver continuous professional education of peripheral health = care=20 staff. A national task force on telemedicine has been working under this = ministry for over two years in formulating policies to facilitate the = growth and=20 integration of telemedicine into health care.7 = During the=20 government=92s next five-year plan, it is expected that new telemedicine = projects=20 will be introduced based on an evaluation of existing telemedicine = projects.

SGPGIMS infrastructure

In 1999, the Department of Endocrine Surgery at the = SGPGIMS=20 started experimenting with the use of videoconferencing to deliver = education to=20 a remote medical college. This followed a successful trial of multisite=20 videoconferencing of a four-day postgraduate course in endocrine surgery = and a=20 workshop on minimally invasive endocrine surgery. Endocrine surgery, as = a=20 subspecialty of surgery, is not well developed in India. To facilitate = knowledge=20 exchange across the country, the department carried out a technical = trial.=20 Gradually, the educational interest expanded to include remote health = care=20 delivery. More projects began, and the telemedicine infrastructure grew. = Currently, the infrastructure at the SGPGIMS telemedicine centre = consists of=20 several telemedicine workstations, equipped with teleradiology, = pathology and=20 videoconferencing units with large display devices. It can carry out = medical=20 data transfer and videoconferencing with six remote locations=20 simultaneously.

The equipment used for telemedicine includes = multimedia PCs with=20 43 cm monitors, as well as studio-type videoconference systems with = flat-panel=20 74 cm television screens. Peripherals include an X-ray digitizer and a=20 trinocular microscope with digital camera attachment. Initially, the=20 connectivity was through a 128 kbit/s ISDN line. Subsequently, = satellite-based=20 connectivity with a 384 kbit/s bandwidth was obtained from=20 ISRO. There is one Ku-band demand = assigned multiple=20 access (DAMA) and an extended C-band very small aperture terminal = (VSAT).

The telemedicine centre at the SGPGIMS uses various = modules in=20 telemedicine care (teleconsultation, tele-follow-up, pre-referral = screening,=20 treatment planning and telementoring), distant medical education and = remote=20 assistance in skill development of health care professionals, as well as = research and development in the field of tele-medicine.8 All=20 telemedicine sessions are real-time.

Partners

The SGPGIMS telemedicine network partners are both = national=20 and international. National partners are listed in Table = 11.1.

The international partners are Ranguil University, = Toulouse,=20 France and the Holy Family Hospital, Rawalpindi, Pakistan. Both of the = overseas=20 centres are connected with 384 kbit/s ISDN.

The technical partners are ISRO, the Centre for = Development of=20 Advanced Computing (CDAC), Pune and Mohali, and the Online Telemedicine = Research=20 Institute (OTRI), Ahmedabad.

Currently, the Orissa Telemedicine Network project is=20 operational and the Uttaranchal network is in the implementation phase. = A=20 network involving eight medical colleges in Uttar Pradesh is being = designed.

Telementoring and tele-education at the=20 SGPGIMS

The first successful telementoring session was = conducted in=20 2004, when a parathyroid tumour removal was performed at the Amrita = Institute of=20 Medical Sciences under expert guidance from the SGPGIMS. There had been = two=20 previous unsuccessful attempts at tumour removal by the same surgeon in = 2001.=20 This experiment was the

Table 11.1 National = telemedicine=20 partners of the SGPGIMS
Institution	Location	Distance from Lucknow = (km)
All three medical colleges of the state of = Orissa	Cuttack, Berhampur and Burla	1500
Two district hospitals of Uttaranchal = State	Almora and Srinagar	500
All India Institute of Medical = Sciences	New Delhi	700
Postgraduate Institute of Medical Sciences and = Research	Chandigarh	500
Amrita Institute of Medical Sciences	Kochi, Kerala	2500
Christian Medical College	Vellore, Tamil Nadu	2000
Rohtak Medical College	Rohtak, Haryana	550

first of its kind reported from India.5,9 The = patient=20 benefited, since he had the operation performed locally, without having = to=20 travel to a distant specialist centre. In fact, the general condition of = this=20 patient was so poor that he could not have travelled to the specialist = endocrine=20 surgical unit. For the telementoring session, both institutions were = provided=20 with dedicated 512 kbit/s VSAT connectivity. Video and audio quality was = good=20 enough for the expert at the SGPGIMS to guide the remote team=20 satisfactorily.

We have also used telementoring as a tool in = subspecialty growth=20 in general4 and = in=20 reinforcing endocrine surgical training.5 This has been done to meet local = requirements,=20 since there is a lack of specialist endocrine surgical centres in India. = As far=20 as structured endocrine surgical training is concerned, only two centres = in=20 India provide the MCh (Master of Surgery) degree. They have an annual = intake of=20 three candidates. In addition to the MCh training, short-course training = (1=963=20 months) is also provided by the department at the SGPGIMS. The = short-course=20 training is reinforced by the use of telemedicine. During a short = training post=20 of three months, the trainees rotate through clinical and laboratory = services=20 and attend all the academic sessions conducted by the department. = Following=20 their return to their parent institute, telementoring is used to monitor = their=20 endocrine surgical practice and to guide them in solving diagnostic = problems, in=20 treatment planning and postoperative care.5 The trainees also receive mentoring = from experts=20 in associated specialties such as nuclear medicine, endocrine pathology = and=20 interventional radiology.5

The tele-CME (continuing medical education) programmes = conducted=20 by the Department of Endocrine Surgery at the SGPGIMS are regularly = transmitted=20 to these trainee locations so that they receive updates on recent=20 developments.10 Table 11.2 = shows the=20 details of the tele-CME transmitted to the medical college in Cuttack, = where two=20 of the short-term trainees are currently located.

The trainees also consult their mentors at the SGPGIMS = in=20 discussing complex endocrine surgical problems, treatment planning,=20 intraoperative and postoperative consultation, and follow-up plan. Figure 11.1 = shows the=20 numbers of such sessions held from 2001 to 2007. Figure 11.2 = shows a=20 tele-CME and a tele-education session in progress.

The benefit of telementoring and tele-education is = that the=20 trainees are able to manage many of the common endocrine surgical = diseases=20 without referring them to the SGPGIMS.5 The added confidence due to the = continuous=20 presence of the mentor

Table 11.2 Conferences, CME = and=20 workshops held
	Year	No. of hours=20 of transmission
5th Postgraduate Course in Endocrine Surgery = (5=20 days)	2001	37
6th Postgraduate Course in Endocrine Surgery = (5=20 days)	2003	40
Indian Thyroid Society Conference	2004	9
7th Postgraduate Course in Endocrine Surgery = (5=20 days)	2005	36
8th Postgraduate Course in Endocrine Surgery = (5=20 days)	2007	34

3DImage=20

Figure 11.1 Number of telemedicine = sessions=20 held per year for reinforcement of training

3DImage=20

Figure 11.2 (a) Tele-CME session in=20 progress

3DImage=20

Figure 11.2 (b) Tele-education = session in=20 progress

increases their output in terms of the range of = endocrine=20 surgical procedures performed and reduces the complication rates.5

Although our initial experience has been successful, = there is a=20 need to develop standards and an accreditation system to facilitate = general=20 adoption of the techniques. The government has now set up a national = task force=20 for telemedicine that is going to address these matters.

Other telementoring and tele-education in=20 India

There are few reports of telementoring in medicine = from other=20 centres in India. However, some institutions, such as the All India = Institute of=20 Medical Sciences and the Apollo Telemedicine Centre, are involved in=20 telementoring experiments (personal communications). The 50-bed hospital = at=20 Aragonda, Andhra Pradesh (in the southern part of India) receives = guidance for=20 managing its patients from the specialists at the Apollo hospitals in = Chennai or=20 Hyderabad. Under expert guidance from specialists at Chennai, the Apollo = Telemedicine Centre at Aragonda has also helped primary care physicians = in=20 making decisions about complex neurosurgical cases and treating certain = minor=20 problems locally without referring them to the tertiary centre at = Chennai.11

Telementoring and tele-education in = other
developing=20 countries

Telemedicine has increasingly been used to solve = certain=20 health care problems faced by the developing world, but there is a = paucity of=20 published reports. This is especially true regarding telementoring. = Until the=20 number of publications increases, it will be difficult to=20 judge the true extent of telemedicine applications being carried out in = the=20 developing world.12

Publications in the field of telementoring in = endocrine surgery=20 from the developing world are very few in number. Even though there is = paucity=20 of telementoring applications in the field of endocrine surgery in = developing=20 countries, there are reports in other specialties. Lee et al13 = reported=20 telementored laparoscopic varicocelectomy and nephrectomy in Bangkok, = Thailand,=20 which was 17 500 km from the mentoring location at the Johns Hopkins = Hospital in=20 Baltimore, USA. This experiment was conducted using ISDN lines at a = bandwidth of=20 384 kbit/s. The authors concluded that transfer of knowledge and=20 teaching=96learning were achieved and that the video pictures = transmitted had=20 acceptable resolution and clarity. Similarly, transcontinental = telementored=20 procedures (laparoscopic bilateral varicocelectomy and a percutaneous = renal=20 access for a percutaneous nephrolithotomy) were carried out in = collaboration=20 between surgeons in Baltimore and Sao Paulo and Recife in Brazil.14

Telementoring has been conducted using low-bandwidth = mobile=20 telemedicine applications to support a mobile surgery programme in rural = Ecuador.15 = This=20 involved a mobile operating room, which was taken to a remote region of = Ecuador=20 (see Chapter = 18). Using=20 a laptop computer equipped with telemedicine software, a = videoconferencing=20 system and a digital camera, surgical patients were evaluated and = operative=20 decisions were made via ordinary telephone lines. The surgeons in the = mobile=20 unit in Ecuador were telementored by an experienced surgeon located at = Yale=20 University in the USA. Apart from five preoperative evaluations, a = laparoscopic=20 cholecystectomy was successfully telementored from the Department of = Surgery at=20 Yale University School of Medicine to the mobile surgery unit in = Ecuador. The=20 use of real-time surgical telementoring to teach complex = ophthalmological=20 procedures was successfully performed in real time via an ISDN line at a = bandwidth of 128 kbit/s from the Saint Francis Medical Centre in = Honolulu,=20 Hawaii, to ophthalmologists at the Makati Medical Center in Manila, = Philippines,=20 more than 8000 km away.16

Telemedicine has also been used asynchronously=20 (store-and-forward) for consultations and patient management by = practitioners at=20 remote location. Vassallo et al17 = reported the=20 establishment of a telemedicine link by the Swinfen Charitable Trust in = July=20 1999, to support a lone orthopaedic surgeon practising in Savar, near = Dhaka,=20 Bangladesh. Evaluation of the telemedicine-based advice for 27 referrals = revealed it to be useful and cost-effective (see Chapter 19).

A trial telemedicine system to facilitate consultation = between=20 medical students pursuing elective study at a remote location in the = developing=20 world and specialists at a central location was established between Gizo = Hospital in the Solomon Islands and Emory University Hospital in = Atlanta, USA. A=20 visiting medical student used this facility to relay images and = investigation=20 reports to specialists in Atlanta. This was used for telemedicine-aided=20 learning, thus providing expert support to medical students in remote=20 locations.18 A = pilot=20 study at the Patan Hospital, Kathmandu, Nepal by the Swinfen Charitable = Trust=20 has shown that a low-cost telemedicine link is technically feasible and = can be=20 of significant benefit for diagnosis, management and telemedicine based=20 education in a developing world setting.19 = Remote=20 monitoring of paediatric patients at the Children=92s Field Hospital in = Gudermes,=20 Chechnya, not only allowed significant number of = patients to=20 be treated locally but also enabled the doctors at the peripheral = location to=20 receive advice about operative techniques20 = (see Chapter 25).

Problems concerning telementoring and = tele-education
in=20 developing countries

Common health care delivery problems faced by = developing=20 countries are infrastructural and organizational in nature. = Infrastructural=20 problems include unreliable electricity supplies, poor telephone = services, lack=20 of transport and lack of medical supplies. Organizational problems = include a=20 lack of CME for health staff, poor training and supervision of health = care=20 workers, shortage of doctors and health care workers, and too many = patients.=20 Telemedicine may be useful in assisting with many of these difficulties. = The=20 major challenges with telemedicine in developing countries are = unrealistic=20 expectations, unsustainable funding models, lack of trials and = evaluation data,=20 and lack of published results and sharing of expertise.

During the audit of the telemedicine programmes at the = SGPGIMS=20 (2001=962005), it was found that only 61% of the scheduled sessions were = held=20 successfully, i.e. 39% of sessions could not be conducted owing to = technical or=20 human resource problems. Technical problems (23%) included power failure = at the=20 remote end, disconnection of the VSAT link and shifting of the VSAT = service=20 (Indian National Satellite System) to a new transponder. Human resource = problems=20 (77%) included non-availability of doctors at the expert end (36%) or at = the=20 remote end (35%), non-availability of technical staff at the remote end = (7%) and=20 others.21

The legal and ethical barriers that are commonly cited = in=20 telemedicine generally are also relevant in developing countries. These = include=20 questions about medicolegal liability and recommendations for good = clinical=20 practice, for which guidelines and protocols are still evolving. This is = especially true for cross-border practice.22 = Other=20 concerns include standards, interoperability, product liability, = intellectual=20 property rights and sharing of health information. Ethical and political = matters=20 need to be addressed.23

At present, professional boundaries are definitely = barriers to=20 the practice of telementoring both within and between countries. This = may be=20 assisted by national health care regulatory bodies or by international = agencies=20 such as the World Health Organization, which in consultation with its = member=20 countries has the potential to develop a global regulatory framework. In = the=20 meantime, accreditation of telementoring-based programmes needs to be = carried=20 out by appropriate agencies in each country or at a global level.=20 Standardization of equipment, networks, technique, professional = competence and=20 process needs to be worked out. Legal questions regarding the sharing of = responsibility as a result of the consequences of actions taken during=20 telementoring must be addressed. There are as yet no guidelines on these = matters. The health care regulatory body within each country needs to = develop=20 legislation for safe practice via telemedicine.

Conclusion

Telemedicine has the potential to improve the = utilization of=20 available resources for health care in developing countries. Our = experience in=20 the specialty of endocrine surgery in India has demonstrated the = effectiveness=20 of telemedicine applications in training, education and skills = development. We=20 have successfully used telementoring for continuous reinforcement of = endocrine=20 surgical training and also in the operating theatre for guided tumour = removal.=20 Even though telemedicine-enabled applications are being explored in = India and=20 other developing countries, few published reports have yet appeared. = Deploying=20 and sustaining telemedicine and telementoring requires the commitment = and=20 support of all those involved if success is to be achieved.

References

1.=20 Rosser JC, Wood M, Payne JH et al. Telementoring. A practical option in = surgical=20 training. Surg Endosc 1997; 11: 852=965.

2.=20 Bruschi M, Micali S, Porpiglia F et al. Laparoscopic telementored = adrenalectomy:=20 the Italian experience. Surg Endosc 2005; 19:=20 836=9640.

3.=20 Mishra SK, Mishra A, Pradeep PV. Telementoring in endocrine surgery. In: = Kumar=20 S, Marescaux J,eds. Telesurgery. Heidelberg: Springer-Verlag,=20 2008.

4.=20 Pradeep PV, Mishra A, Kapoor L et al. Surgical sub-specialty growth in=20 developing country: impact of telemedicine technology; a case study with = endocrine surgery. In: Proceedings of the 8th International = Conference on=20 E-Health Networking, Application and Services (Healthcom 2006), New = Delhi:=20 34=969.

5.=20 Pradeep PV, Mishra A, Mohanty BN et al. Reinforcement of endocrine = surgery=20 training: impact of tele-medicine technology in a developing country = context.=20 World J Surg 2007; 31: 1665=9671.

6.=20 Ministry of Communications and Information Technology. Recommended=20 Guidelines & Standards for Practice of Telemedicine in India. = Available=20 at:=20 www.mit.gov.in/telemedicine/Report%20of%20TWG%20on%20Telemed%20Standardis= ation.pdf.

7.=20 Mishra SK, Gupta SD, Kaur J. Telemedicine in India: initiatives and = vision. In:=20 Proceedings of the 9th International Conference on E-Health = Networking,=20 Application and Services (Healthcom 2007), 19=9622 June, Taipei, = Taiwan:=20 81=963.

8.=20 SGPGI. Telemedicine. Available at: www.sgpgi-telemedicine.org.

9.=20 Pradeep PV, Mishra SK, Vaidyanathan S et al. Telementoring in endocrine = surgery:=20 preliminary Indian experience. Telemed J E Health 2006;=20 12: 73=967.

10. Pradeep = PV, Mishra=20 A, Kapoor L et al. Applications of tele-health technology in endocrine = surgery:=20 Indian experience. In: Proceedings of the Telemedicine 2007 = Conference,=20 31 May=961 June 2007, Montreal, Canada.

11. = Ganapathy K.=20 Telemedicine and neurosciences in developing countries. Surg = Neurol=20 2002; 58: 388=9694.

12. Wootton = R.=20 Telemedicine and developing countries =96 successful implementation will = require a=20 shared approach. J Telemed Telecare 2001; = 7(Suppl 1):=20 1=966.

13. Lee BR, = Bishoff J=20 T, Janetschek G et al. A novel method of surgical instruction: = international=20 telementoring. World J Urol 1998; 16: = 367=9670.

14. = Rodrigues Netto N=20 Jr, Mitre AI, Lima SV et al. Telementoring between Brazil and the United = States:=20 initial experience. J Endourol 2003; 17: = 217=9620.

15. Rosser = JC Jr, Bell=20 RL, Harnett B et al. Use of mobile low-bandwith telemedical techniques = for=20 extreme telemedicine applications. J Am Coll Surg 1999;=20 189: 397=96404.

16. Camara = JG,=20 Rodriguez RE. Real-time telementoring in ophthalmology. Telemed = J 1998;=20 4: 375=967.

17. Vassallo = DJ,=20 Swinfen P, Swinfen R, Wootton R. Experience with a low-cost telemedicine = system=20 in three developing countries. J Telemed Telecare 2001;=20 7(Suppl 1): 56=968.

18. Mukundan = S Jr,=20 Vydareny K, Vassallo DJ et al. Trial telemedicine system for supporting = medical=20 students on elective in the developing world. Acad Radiol 2003; = 10: 794=967.

19. Graham = LE,=20 Zimmerman M, Vassallo DJ et al. Telemedicine =96 the way ahead for = medicine in the=20 developing world. Trop Doct 2003; 33: = 36=968.

20. Ehrlich = AI,=20 Kobrinsky BA, Petlakh VI et al. Telemedicine for a children=92s field = hospital in=20 Chechnya. J Telemed Telecare 2007; 13: = 4=966.

21. Kapoor = L, Basnet=20 R, Chand RD et al. An audit of problems in implementation of = telemedicine=20 programme. In: Proceedings of the 9th International Conference on = E-health=20 Networking, Application and Services, 19=9622 June 2007, Taipei, = Taiwan:=20 87=969.

22. = Stanberry B. Legal=20 and ethical aspects of telemedicine. J Telemed Telecare 2006;=20 12: 166=9675.

23. Kapoor = L, Basnet=20 R, Pradeep PV et al. Integrating telemedicine in surgical applications.=20 Comput Soc India Commun 2007; 30: = 17=9620.

SECTION 4
CLINICAL

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12 Teledermatology in developing = countries

Steven Kaddu, Carrie Kovarik, Gerald Gabler = and H Peter=20 Soyer

Introduction

The inherent visual nature of dermatology makes it = suitable=20 for telemedicine. Several teledermatology projects have recently been = initiated=20 in developing countries, and the number is gradually increasing.1=967 = Preliminary=20 results underline a number of potential benefits to patients, remote = health care=20 workers and health care systems of host countries. These benefits (Box 12.1) = include easy=20 extension of specialized dermatological services to geographically = remote areas=20 with few dermatologists, reduction of patients=92 waiting time for = appointments,=20 faster screening for skin diseases, promotion and coordination of = scientific=20 health projects, and education of health workers and lay people.1=966,8 = Local=20 physicians benefit from the mentoring and educational aspects of the=20 consultations, as well as the access to improved research facilities and = professional

Box 12.1 Potential benefits = of=20 teledermatology

Benefits to = patients

= Enhanced=20 access to a trained dermatologist

= Prompt=20 specialist opinion, leading to more accurate diagnosis and = treatment=20 outcomes

= Reduction of=20 patient=92s waiting time

= Reduction of=20 travel expenses

Benefits to local health care=20 workers

= Improved and=20 efficient access to specialized dermatology care

= Improved=20 management of patients with skin problems

New=20 opportunities for continued medical education

= Enhanced=20 professional collaboration

= Enhanced=20 collaboration in research

= Access to=20 online atlases and databases

More = efficient=20 screening of patients with skin problems

= Better=20 follow-up of patients with selected skin problems

Benefits to local health care=20 system

= Reduction in=20 health care costs

= Reduction in=20 patient=92s and physician=92s travel costs

= Reduction in=20 total number of hospital admissions, as well as faster=20 discharges

= Increase=20 efficiency in the use of human resources

= Increased and=20 effective support for local health professionals

= Compilation of=20 online databases

interactions. Consulting experts also get special=20 opportunities to review rare or unusual dermatological cases.

As in other telemedicine systems, teledermatology = employs both=20 store-and-forward methods (asynchronous) and real-time approaches=20 (synchronous).9 Both = modalities have previously been shown to be quite reliable and accurate = when=20 compared with traditional face-to-face consultation.9=9613=20 Store-and-forward systems are more widely used, owing to their lesser=20 technological requirements and affordability. Images are submitted by = email or=20 presented on a web-based system. Although the real-time approach = represents a=20 reasonable substitute for in-person consultation and has the advantage = of=20 enhancing patient=96doctor interaction, it is more time-consuming and=20 expensive.

Teledermatology may involve providing assistance, = follow-up or=20 teaching. Tele-assistance models aim at teleconsultation, telescreening = and/or=20 second opinion.7,14 = The majority=20 of teledermatology projects in developing countries deal with = dermatology=20 consultations. Telescreening projects have been used to manage waiting = lists for=20 treatment of dermatoses with different healing times or to support = prevention=20 programmes such as those surveying skin tumours.15=20 Telefollow-up systems deal with transmission of medical information = regarding=20 follow-up and treatment progression of patients from remote centres = (e.g. to=20 follow up patients treated for certain chronic skin conditions such as = leg=20 ulcers and leprosy) and for postoperative evaluation.5,16=20 Tele-education is proving to be a versatile model, helpful in staff = development=20 such as by tutoring and assessing medical and paramedical workers.7 Most = teledermatology collaborative projects also involve some degree of=20 tele-education in addition to tele-assistance. Thus, in addition to=20 long-distance consultation, they also provide continuing medical = education (CME)=20 for physicians who submit cases. Applications for tele-education mainly=20 integrate text and images (static or dynamic) and/or virtual reality = models to=20 achieve health education.

The use of web applications for discussion forums = represents=20 another application of teledermatology. The main objective of such = applications=20 is to create a quick and easy method for teleconsultation from a pool of = expert=20 consultants. The philosophy behind these =91DermOnline=92 communities is = open access=20 teleconsultation in dermatology, which means that these platforms are = free to=20 all users and that the users themselves generate the content by sending = and=20 answering the teleconsultations. These communities have moderators who = check=20 both the subscribers and the content of the requests in order to = guarantee=20 friendly and orderly virtual interaction.

Teledermatology in developing = countries

There are several teledermatology networks and = projects in=20 developing countries.

The telederm.org application and=20 networks

The telederm.org application was = initiated by=20 the Department of Dermatology of the Medical University of Graz, = Austria, in=20 2002. The primary goal was to develop a software = application=20 that would facilitate worldwide exchange of knowledge and expertise in=20 dermatology and dermatopathology. The application is now used by several = teledermatology networks, some of which are active in developing = countries,=20 including the telederm.org project and the = Africa=20 Teledermatology Project.7,17=9619 = Versions of=20 the application are available in German, Italian, Chinese, Turkish = languages,=20 Serbian and Hebrew.

The program provides the functionality to store and = forward=20 medical cases with attached images. Within a particular network, users = are=20 categorized as either clients or experts. Clients can only submit cases = to=20 selected experts, whereas experts have the right to review cases, write = comments=20 and suggest a diagnosis, or further forward cases to other selected = experts=20 within the system (Figure 12.1). = All users=20 can subscribe for notifications so that they get an automatic email if, = for=20 example, a new comment is added to one of their cases or if a new case = is=20 entered on the site. Every network has at least one administrator who is = able to=20 register users and/or reassign consultations to preferred experts.

3DImage=20

Figure 12.1 Africa Teledermatology = project=20 data flow

All requests are archived in a database with a = personal archive=20 for each user. A client can choose to send a request for consultation = only to a=20 selected expert, or he or she can submit a request to an open forum as a = =91discussion case=92. In the former situation, the user receives a = personal answer=20 and interactions remain private. Cases submitted as =91discussion = cases=92 are=20 visible to all users, who can review the cases and submit on-line = opinions.

The telederm.org = project

This teledermatology network was initiated in April = 2002 with=20 the aim of creating an easy-to-use platform for teleconsultation = services where=20 physicians could seek diagnostic advice in dermatology from a pool of = expert=20 consultants and discuss challenging cases.18 An = online=20 discussion forum was included in October 2003. At present, more than = 1300=20 physicians are subscribed to the telederm.org project from over = 90=20 countries worldwide. Through this application, participants from = different=20 medical specialties are matched with dermatologists with a range of = experience=20 in diagnosis and management of various skin diseases. By providing a = platform=20 for interactive discussion between physicians at the point of care and = experts=20 from different countries, the telederm.org project seeks to = raise the=20 level of competence of physicians and dermatologists at the point of = care on a=20 worldwide level.

The telederm.org project is a = non-profit=20 venture under the auspices of the International Society of = Teledermatology. The=20 main academic institutions involved are the Department of Dermatology, = Medical=20 University of Graz, Graz (Austria) and the Dermatology Group, School of=20 Medicine, University of Queensland, Brisbane (Australia). Moderators of = the=20 telederm.org=20 community come from a range of different countries, including Turkey, = Croatia,=20 Romania, China, Pakistan, USA and India. The telederm. org project has = 1024=20 users, with an average of 38 new users per month. It handles about 27 = new cases=20 per month.

The Africa Teledermatology project

The Africa Teledermatology project20 = was=20 initially conceived as the =91Uganda Tele-Dermatology- and = E-Learning-Project=92 in=20 February 2007, with sponsorship from the Kommission f=FCr = Entwicklungsfragen (KEF)=20 der =D6sterreichischen Akademie der Wissenschaften. Its main objective = was to=20 facilitate improvement of the treatment of skin diseases in Uganda by=20 establishing an Internet channel for long-distance dermatological = consultation=20 between the medical Universities of Makerere and Mbarara in Uganda and = the=20 Department of Dermatology, University of Graz. In collaboration with the = Department of Dermatology at the University of Pennsylvania, USA, the = scope of=20 the project was expanded, with the eventual inclusion of a number of = other=20 medical centres in eastern, central and southern Africa, which led to = the=20 formation of the Africa Teledermatology project. The main purpose of = this work=20 is to support African health workers in the diagnosis and management of = patients=20 with skin diseases, especially those having skin conditions related to=20 HIV/AIDS.

The Africa Teledermatology project uses the telederm.org = application=20 (Figure = 12.2). There=20 are links on the application homepage to educational resources and a = dermatology=20 curriculum. An online archive of tropical skin conditions should = emerge

3DImage=20

Figure 12.2 Dematologists and = medical staff at=20 Mbarara university hospital, Uganda selecting and processing difficult = cases of=20 skin diseases for teleconsultation

that will serve as an Internet source of educational = material=20 for training and updating of medical specialists and health personnel. A = secondary goal of the project is to establish a platform for dermatology = research collaboration. The ultimate objective is the integration of the = various=20 aspects of teledermatology and teledermatopathology into health care = systems of=20 developing countries.

In the first 12 months, 160 teledermatology-supported = patient=20 encounters have been processed. Of these, 35% of cases were children and = 25%=20 represented HIV-associated skin conditions. A number of Internet = learning=20 facilities for medical personnel have been set up on the project = website,=20 including an online case presentation with discussion, dermatology = lectures and=20 an international forum of physicians with an interest in tropical = dermatology.=20 Through this initiative, scientific cooperation has been established = with a=20 number of specialists from well-known medical/dermatology centres = worldwide, who=20 have contributed their experience in management of difficult skin = conditions=20 submitted by colleagues in Africa.

iPath application and = networks

The iPath software was developed by the Department = of=20 Pathology of the University Hospital Basel as an open source framework = for=20 building web- and email-based tele-medicine applications.21=9623 = iPath=20 provides the functionality to store medical cases with attached images = and other=20 documents in closed user groups. Within these groups, users can review = cases,=20 suggest diagnoses and submit comments. In addition, users can subscribe = for=20 notifications so that they receive an automatic email message if, for = example, a=20 new comment is added to one of their cases or if a new case is entered = in a=20 group. All users are organized into one or more discussion groups. Every = discussion group has at least one moderator who can assign other users = to the=20 group and who can delete erroneous data.

At present, iPath hosts several telemedicine networks = active in=20 developing countries, several of which involve teledermatology. These = include=20 the following.

Solomon Islands National Telemedicine = Network

This is a joint project of the National Referral = Hospital in=20 Honiara, South Pacific Medical Projects and the University of Basel.24 It = aims to=20 use telemedicine to improve health care delivery in provincial hospitals = in the=20 Solomon Islands. There is special emphasis on the fields of dermatology, = radiology, orthopaedics and paediatrics.

LT Telepatologija

This is regional network of pathologists and other = medical=20 specialists in the Baltics, based on the iPath platform.25 = Its purpose=20 is to support clinicopathological case discussions, consultations and = CME.

RAFT-Forum (telemedicine platform of the R=E9seau = de=20 T=E9l=E9-enseignement et de T=E9l=E9m=E9decine en Afrique = Francophone)

The main activity of this forum is the webcasting of = interactive courses for physicians and other health care workers in=20 French-speaking countries of Africa, including Mali, Mauritania, = Senegal,=20 Morocco, Tunisia and Madagascar.26 = The main=20 goal is to encourage knowledge sharing across = medical=20 institutions in the various participating countries. Topics for = discussion are=20 proposed by the partners of the network. The technology used for the = webcasting=20 works with an Internet connection, a Java-enabled web browser (e.g. = Internet=20 Explorer or Mozilla) and the free software RealPlayer.

Telemedicine Sur

This is a telemedicine platform for medical = discussions, CME=20 and consultations for medical specialists and health practitioners in = Latin=20 America.27 = Specialties=20 involved include mainly pathology, dermatology and venereology, as well = as=20 paediatrics.

West Africa Doctors and Healthcare Professionals=20 Network

This is a West African telemedicine network, again = based on=20 the iPath software.28 = Its goal is=20 to enhance the communication capabilities of doctors, particularly in = the areas=20 of information access, distance learning (CME), telemedicine- and=20 knowledge-based support of diagnosis, and management of patients in = various=20 specialties.

HealthNet Nepal

This is a health information and communication = network in=20 Nepal that provides low-cost email, Internet access and a wide range of = medical=20 and public health resources to the Nepalese health community.29 = The network=20 began in 1994, and is subscribed to by over 230 health institutions and=20 organizations, including hospitals, clinics, university departments, = research=20 sites and non-governmental organizations (NGOs) in both urban and rural = areas.=20 The network enables health professionals throughout Nepal to communicate = and=20 exchange knowledge.

Teledermatology project in Port St Johns, South=20 Africa

Thi

Telehealth in the Developing World

Contents

Contributors

Foreword

Preface

SECTION 1BACKGROUND

1 Introduction

What is telemedicine?

Scope of the problem

Crisp report

Aim of the book

References

SECTION 2POLICY

2 Bridging the digital divide: Linking health and = ICT=20 policy

Introduction

ICT in the health sector

Measuring the digital divide

Driving forces for ICT in health

Challenges in global public = health

Forces for change

An overview of ICT policy

Interested parties

Pivotal role of = governments

Linking health goals to ICT = policy

Linking health and ICT policy

Core content of ICT policy

Factors affecting ICT use in the health=20 sector

Costs for ICT

Access speed

Education

Collaboration between stakeholders

Legal framework, skills and protections for = anetwork=20 economy

ICT policy orientation in middle- and = high-income=20 countries

ICT policy orientation in low- and = middle-income=20 countries

Opportunities presented by policy reform=20 processes

Policy adjustment to meet local=20 needs

Opportunities for action

A holistic approach to ICT = development

Making the case for health

Outlook for the future

Conclusion

Acknowledgements

Further reading

References

3 Telemedicine in developing countries: = Perspectives from=20 the Philippines

Introduction

The human experience

Community Health Information Tracking=20 System

The technological opportunity

E-Learning for Health = Project

The sustenance factor

SMS Telemedicine Project

Conclusion

Further reading

References

4 Information technology for primary health care = in=20 Brazil

Introduction

IT in primary care in Brazil

National Telemedicine = Programme

National information = systems

Telemedicine

Computerized tools

PACOTAPS

Training

Survey results

Conclusions

Further reading

References

5 Community-based health workers in developing = countries=20 and the role of m-health

Introduction

Opportunities in m-health for addressing = globalhealth=20 problems

Primary health care

Case study summary

Technology interfaces

Social

Finance

Government

Conclusion

Further reading

References

SECTION 1
BACKGROUND

SECTION 2
POLICY

Legal framework, skills and protections for = a
network=20 economy

Opportunities in m-health for addressing = global
health=20 problems

Role of national governments in=20 promoting
e-health

SECTION 3
EDUCATIONAL