GAID White Paper on ICT4D Health

8/9/2019 GAID White Paper on ICT4D Health

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White PaperInformation &

CommunicationTechnologies for

Development: Health

Authors:

Andrea Bord

Charles Fromm

Farzad Kapadia

Doriana S. Molla

Eleece Sherwood

Jane Brandt Srensen

The New School University

Graduate Program in

International Affairs

Advisor:

Ambassador Rafat Mahdi

asdf

E c o n o m i c


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ICT for Deve lopment : Hea l th

Table of Contents:

1. INTRODUCTION.................................................................................................................................................1

2. INTERSECTION OF HEALTH AND ICTs...........................................................................................................2

3. ICTs AND THE MDGs........................................................................................................................................2

3.1 eHealth and mHealth: Challenges and Opportunities.................................................................................3

4. ROLE OF GOVERNMENTS FOR IMPROVED HEALTH..................................................................................4

4.1 National Health Plans......................................................................................................................................4

4.2 Innovative Health Plan Initiatives...................................................................................................................5

5. NATIONAL COMMITMENT TO HEALTH FINANCING..................................................................................5

5.1 Health Expenditure Analysis...........................................................................................................................5

5.2 Public-private Partnerships for eHealth........................................................................................................6

5.3 The High Cost of Access to eHealth Devices...............................................................................................7

6. ROLE OF CIVIL SOCIETY....................................................................................................................................8

6.1 Civil Society and Health....................................................................................................................................9

6.2 Involvement of Civil Society at the Program Level....................................................................................10

7. TECHNICAL AND HUMAN CAPITAL CONSTRAINTS................................................................................10

8. MONITORING AND EVALUATION................................................................................................................11

8.1 Easy Use of PDAs............................................................................................................................................12

8.2 Cracking Health Stigmas................................................................................................................................12

8.3 Shorter Wait Times for Patients....................................................................................................................12

8.4 Medical Data Collection and Country Staff Development........................................................................12

8.5 ICT for Health Education................................................................................................................................13

9. LESSONS LEARNED........................................................................................................................................13

9.1 Financial Sustainability of ICT Projects.......................................................................................................13

9.2 Lack of English Skills and Education as a Road Block to ICT...................................................................14

9.3 Effective Counseling against Stigmas.........................................................................................................14

9.4 ICT for Health, Technical and Human Capacity.......................................................................................14

9.5 Reluctance of Governments and Private Companies...............................................................................15


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9.6 Medical misdiagnoses Using ICT..............................................................................................................15

9.7 Role of Civil Society and Public-Private Partnerships..............................................................................15

10. RECOMMENDATIONS....................................................................................................................................15

10.1 For Governing bodies.....................................................................................................................................16

10.2 For International Organizations and Donors...............................................................................................16

10.3 For Civil Society...............................................................................................................................................16

10.4 For Private Entrepreneurs..............................................................................................................................16

10.5 When Implementing ICT for Health..............................................................................................................17

11. APPENDIX........................................................................................................................................................18

Figure 1.............................................................................................................................................................18

Figure 2.............................................................................................................................................................20

Figure 3.............................................................................................................................................................21

Figure 4.............................................................................................................................................................22

Figure 5.............................................................................................................................................................23

Figure 6.............................................................................................................................................................23

Figure 7.............................................................................................................................................................24

LIST OF ACRONYMS.....................................................................................................................................................25

ENDNOTES.....................................................................................................................................................................27


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1. Introduction

At the G8 Kyushu-Okinawa Summit in July 2000 member states of the industrialized countries focusedon the impact of information technologies and the growing challenges and risks of a global digital

divide. The summit recognized that Information and Communication Technologies (ICT) can serve as

effective tools for broad-based international development in regions where developments traditional

toolkit has fallen short. The United Nations (UN) has paid particular attention to the role of ICT in ad-

vancing the Millennium Development Goals (MDGs) through its UN ICT Task Force and the World Sum-

mit on Information Society.

In recent years, the international community has rallied around a campaign known as Information and Com-

munication Technologies for Development (ICT4D), which aims to apply information technology solutions

toward poverty reduction goals. ICTs can be applied directly wherein their use benets a disadvantaged

population, or indirectly where ICTs assist aid organizations, non-governmental organizations (NGO), gov-

ernments or businesses in order to improve existing socio-economic conditions.

For the purposes of this report, ICTs are dened as tools that facilitate communication and the processing

and transmission of information and the sharing of knowledge by electronic means. This encompasses the

full range of electronic digital and analog ICTs, from radio and television to telephones (xed and mobile),

computers, and electronic-based media such as digital text, audio-video recording, and the Internet, includ-

ing Web 2.0 and 3.0, social networking and web-based communities.1

This white paper was commissioned at the request of The Global Alliance for Information and Communica-

tion Technologies and Development (UNGAID), a United Nations body launched in 2006, which remains at

the forefront of highlighting the relevance of ICT for development. The network emerged out of the 2005 UN

Summit emphasizing ICT involvement for development goals with a special focus on the MDGs.

UNGAID serves as a global forum addressing issues closely tied to ICT diffusion, relevancy, and implications

in development. UNGAIDs mission stresses the importance of a multi-stakeholder approach, following the

belief that a people-centered and knowledge-based information society is essential for achieving better life

for all. UNGAID has partnered with other UN agencies, the private sector, academia and the ICT industry to

help develop these ICT solutions.2

This report will review examples from different regions of the world where ICT programming focuses on

combating HIV/AIDS and malaria, decreasing child mortality and improving maternal health. Relevant cas-

es of ICT applications and their effectiveness in improving health services in developing countries will be

examined. The aim is to take into consideration the costs and benets of ICT solutions in healthcare without

losing sight of long-term impact on development.

The thirteen economies selected for this work represent a broad range of developing and transitory coun-tries chosen from various regional groupings. The countries detailed through the paper are: Albania, Esto-

nia, India, Jordan, Macedonia, Malawi, Peru, Qatar, South Africa, Tanzania, Trinidad and Tobago, Uganda

and Vietnam. See Figure 1 for detailed descriptions of the selected featured initiatives. Additionally, for an

overview of progress made on the three health MDGs in these countries refer to Figure 2.


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3.1 eHealth and mHealth: Challenges and Opportunities

In recent years, mHealth and telemedicine have emerged as important initiatives in the eld of eHealth.While there is no widely agreed-to denition for these elds, the public health community has gathered

around these working denitions (see Figure 3 for greater detail):

eHealth: Using information and communication technologies (ICT)such as computers, mobile

phones, and satellite communicationsfor health services and information.

mHealth: Using mobile communicationssuch as PDAs and mobile phonesfor providing remote

health services and information.

Telemedicine: solutions that are designed to deliver a clinical presence in remote health services.9

Due to the limitations of todays mobile technology (specically, bandwidth and transmission speed), the

distinguishing element of telemedicine clinical presence (imagery, video or other real time diagnosticinformation) is best delivered through xed line or wireless networks. As both mobile technology and

bandwidth continue to evolve, the overlap between telemedicine and mHealth will continue to increase

through services like mobile broadband.

To date, serving targeted populations, such as the rural poor, has posed the greatest challenge to mHealth

projects spread throughout the globe. The ability to demonstrate scale incentivizes key players in the

mHealth value chain, for instance, a mobile network provider would need to be assured high levels of trafc

before agreeing to participate. Large numbers of unique text messages or scalable and robust behavioral

change will entice platform and application developers.10 The more scale that can be displayed, the easier

it will be to coalesce partners that are truly invested in the program.

Using new methods of delivery vastly improves the penetration of basic health services across the develop-

ing world. For this to happen, the sector needs to bolster its effectiveness - delivering care to those who

have previously received none - with partnerships rooted in business interests. The issue of scale and sus-

tainability must be emphasized here, since relationships based on prot motive are easier to sustain during

periods of economic turmoil.

Central to the success of any mHealth application is consistent funding and the ability to retain larger value

chain partners, i.e. telecommunications providers. These companies are under intense pressure from senior

management and stockholders to remain protable and increase market share, making it difcult to justify

any venture whose sustainability has yet to be proven. Priority of mHealth developers should be based on

ensuring both sustainability and scale, as a measure of wider success in improved health care delivery.

4. Role of Governments for Improved HealthGovernments play a major role in determining immediate national priorities while also working towards

long-term development plans. Healthcare remains a crucial component of development strategies under-

taken by governments requiring political capital, nancial resources, and organizational capacities to be

fully invested in the process.

Under the MDGs, increased focus has been given to the role that governments play in bettering health care

delivery via their national health plans and ICTs. This section serves as a progress report, highlighting the


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successful initiatives undertaken by selected country governments as well as indicating where more human

and nancial capital is necessary.

4.1 National Health Plans

In terms of positive examples, Ugandas Government has made huge strides in making ICT a priority and

using it to deliver healthcare to its populace by building considerations for ICT into its national health

plan. Ugandas national vision is to promote development and effective utilization of ICT such that quan-

tiable impact is achieved countrywide in line with the national Poverty Eradication Action Plan and the

MDGs. The Government has given special consideration to ICT in the 2009 Uganda Health Sector Strate-

gic Plan, which identies the mainstreaming and integration of ICTs into health care delivery as part of

the National Health Policy.

However it remains to be seen how Uganda will strengthen its institutional capacity while simultaneously

bolstering its scarce human resources, the success of which will reveal the extent to which ICT applicationshave been mainstreamed into Ugandan healthcare. Despite the complexities facing the Ministry of Health

in Uganda, the shared objective aims at a 20% increase in the use of telemedicine in all health care centers

by 2010.11 Recommendations for Governments such as Uganda, who have taken concrete steps to integrate

ICT into their national health policies, would be to keep building upon the foundations already laid, in order

to capitalize on existing achievements that utilize ICT in order to bring the maximum amount of healthcare

resources to communities that need them.

In Qatar, the Hukoomi Supreme Council of Health, the main government ministry of health, has implemented

a comprehensive health system focused on using ICT as its backbone. The mandate of the e-Health plan in

Qatar is to combat and monitor non-communicable diseases, such as diabetes and high blood pressure. The

focus towards non-communicable diseases reects the needs of the Qatari health arena where there exists

a higher prevalence of non-communicable diseases and lifestyle conditions.

Peruvian national health plans adopted in recent years have also seen great success; the plans aim to en-

hance the quality of healthcare provided to the elderly, women, children and people with disabilities. The

Ministry of Health focuses primarily on the implementation of an integrated health insurance system to re-

duce maternal mortality, HIV prevention programs, and to make healthcare accessible to the poor.12 Perus

pioneering achievements in healthcare management have led it to become a model country in the region

per the health related MDGs.13 But whereas ICT is growing signicantly in other sectors, this is unfortu-

nately not the case in the health sector. The country must leverage existing ICT successes to make progress

in indigenous and rural regions where child mortality and HIV/AIDS rates remain alarmingly high.

In Tanzania, there is no clearly dened national ICT plan aimed at the healthcare, even though ICT solutions

have seen increased numbers in the health sector. Thus, ongoing ICT projects in health are not consolidatedand they are managed poorly for countrywide implementation. Gradually, reliable access to Internet has

been achieved and some hospitals have taken advantage. However, the present systems are weakened

by poor maintenance of computers and network infrastructures, as well as frequent attacks of computer

viruses. It appears that currently, opportunities for web-based communication and collaboration are insuf-

ciently used.14

While South Africas ICT sector continues to see growth, absence of government action in tackling the HIV

epidemic in the country has had a profoundly negative impact. Progress on the MDGs has been insufcient


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and in some cases reversed. Lack of coordinated government action has seen the emergence of a multi-

drug resistant tuberculosis outbreak leading to a number of preventable deaths, and early gains on maternal

mortality have been reversed by the increasing number of pregnant women with HIV.15 It can be argued thatthe South African health model could be aided by further ICT implementations like disease monitoring solu-

tions, and mobile health education campaigns against HIV/AIDS.

4.2 Innovative Health Plan Initiatives

In Tanzania, the health SWAp (Sector Wide Approach), a government-sponsored initiative, introduced in

1999, has improved access to and delivery of health interventions. An independent evaluation conducted by

the WHO found the program to have reduced infant mortalities, increased access to pharmaceuticals and

has led to improved quality of health services.16 It aims at increasing transparency, improving predictability

and allocation of nancing, reduced transaction costs and reduced administrative demands placed upon

government. The SWAp Committee is the agreed overall body for dialogue among all stakeholders in health.

SWAp keeps an eye toward bringing to the table all concerned parties from civil society to governmenthealthcare ofcials.17

Indias National Rural Health Mission (NHRM) also represents a break from the status quo in nancing

health care in rural geographies. A notable element of the program is the governments commitment to in-

crease public health spending from 0.9% to 2-3% of Gross Domestic Product (GDP) over the next ve years,

and introduce mechanisms to ensure funding reaches its intended recipients. Approximately US$2 billion

was allocated for the NRHM. The Ministry of Labor has supplemented the program by unveiling a national

hospitalization scheme for poor families. Families living beneath the poverty line are entitled to hospitaliza-

tion coverage of up to Rs. 30,000 for most diseases requiring hospitalization, and pay a Rs. 30 registration

fee, the balance of the costs are split between state and federal governments.18

5. National Commitment to Health Financing

How much national governments spend on health care is unlikely to provide an accurate picture of the over-

all benets their citizens receive as a result. This section looks to provide some comparison and analysis for

the selected countries of health expenditure statistics as reported by the WHO. Countries will be analyzed

and compared across and within region. The indicators to be analyzed are general government expenditure

versus private expenditure as a % of total expenditure on health; external resources for health as a % of

total expenditure on health; and per capita expenditure on health. All percentages and gures in this sec-

tion are from 2006, unless otherwise noted. Figure 4 displays how health expenditures are prioritized in the

selected countries.

5.1 Health Expenditure analysisThe sum of general and private expenditure towards health care makes up a countrys total expenditure on

health. Government expenditure should outweigh the private percentage, so that a countrys low-income

populace will have access to subsidized health care, as privatized health care is rarely an option for low-

income individuals.

A WHO survey bolstered the claim that eHealth depends primarily upon public funding with a far lesser pro-

portion of countries also using private funding or public-private partnerships to support activities.19


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Of all the selected economies, Estonia maintained the lowest ratio of private health expenditure at 26.7%

while government spending accounted for 73.3% of all healthcare nancing. The Estonian eHealth Founda-

tion is primarily nanced from the state budget. Estonia participates in several cross-European projectsco-nanced through various EU programs. The most unfavorable balance of public to private spending was

seen by India, where private expenditure accounted for 75% while the government only mustered 25% of

total expenditure on healthcare.

The regional trends mirrored those seen in individual countries as the transition economies of Estonia and

TFYR Macedonia combined, saw their governments make up 72% of spending while private health care

spending made up 28.1% of all expenditures. Asia (Vietnam and India) lagged behind with their governments

spending only 28.7% toward healthcare, the remainder, 71.4% was nanced through private channels.

External resources for health are dened as the sum of resources channeled towards health by entities

outside a nations borders, including donations and loans, and both cash and in-kind resources. This gure

is expressed as a percentage of total expenditure on health. The percentage provides a good indicationof the amount of external funding a country requires in meeting its health care needs. Here the standout

was Qatar, who since 2000 has not required any external nancing to meet its health care needs. Estonia

and South Africa come in close seconds requiring only 0.6% and 0.9% respectively, of total expenditure on

health to come from external resources in 2006.

By contrast, Malawi acquired 59.6% of it total health expenditure via external actors. Peru and Trinidad

and Tobago saw only 1.5% and 2.4% respectively, of health expenditure being channeled in externally.

Regionally, Africa did not fare well seeing up to 33.9% of its total health expenditure, ooding in from

outside the continent.

Per capita government expenditure on health indicates the dollar amount of health expenditure a govern-

ment spends per citizen. This is not to say that every citizen receives the same proportion of health carebenets. More often than not, the amount spent by the government far exceeds the dollar value of benets

received by the recipient. The gure is however, a gauge for the robustness of particular health systems

nances. For instance, Sweden, a country with arguably one of the best public health care systems in the

world spends US$ 3,245 per citizen, an impressive sum.

Of the selected countries, Qatar was again a clear frontrunner, their health expenditures per citizen amount-

ed to US$ 2,157. Trinidad and Tobago was next at US$ 103 per inhabitant, indicating the massive gap that

needs to be made up by the remainder of the selected countries. Uganda spent the least per national at

US$ 6; India too also spent a very low amount of US$ 7 per resident. This however should be considered in

context of Indias billion plus population.

Regional averages highlighted some interesting trends. Asia spent the lowest per inhabitant at US$ 11, while

the transitional European economies placed well spending on average of US$ 320 per capita. The Middle

East and Latin American countries spent US$ 265.50 and US$ 213 per capita, respectively.

5.2 Public-private partnerships for eHealth

Much of the funding for eHealth projects is derived from outside ministry of health coffers. The projects typi-

cally contain a dose of public private partnerships to nance the costs and the partnerships are supported

via technical assistance and monitoring evaluation through a number of NGOs, international corporations

and increasingly often, by universities.


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Perus Colecta-PALM project was born out of a partnership between the University of Washington and the

Peruvian University of Cayetano Heredia. As with other projects two local partners provided valuable on the

ground insight into local conditions and customs; Asociacin Via Libre and Asociacin Civil Impacta Salud yEducacin. The two Peruvian health clinics were instrumental in allowing the universities to administer the

surveys to their patients along with providing staff time to support the scheme.20 21

The CA:SH project in India was made possible because of a partnership between a multitude of stakehold-

ers; including Media Lab Asia (part of Indias Ministry of ICT and a privately-held software company),and the

All India Institute of Medical Sciences.22 Given the nature of the mobile healthcare software, highly skilled

engineers and doctors are needed to make successful tools, which require tremendous nancial support.

This initiative is a model example of the private sector, government and academia, working in concert to

better serve the public.

Microsoft and Boeing Corporation are among some of the private funders that have funded Jordans

Knowledge Stations project and the general development of Jordans ICT sector.23 These particularfunders have been instrumental in making sure Jordans ICT sector continues using the most up-to-date

health software, so that its system stays cutting edge. The Knowledge Stations and Jordans ICT sector

are also funded by external donors such as the Peoples Republic of China, the Republic of Korea, and the

Japanese government.24

Project M in South Africa is a rather unique combination of stakeholders including private media and

design rms, NGOs and government agencies, South African foundations and leading mobile technology

companies. MTN, one of the largest telecommunication companies in the developing world with more

than 74 million subscribers across the world, is donating up to 1 million Please Call Me messages per

day for two years.

The project has received modest funding from individuals and capital donors and signicant in-kind donationsfrom core project partners. Cash donations total US$ 250,000, and in-kind contributions are valued at millions

of dollars. The project is cost-effective and delivers HIV/AIDS information to the population of South Africa at

virtually no cost, because of the MTN donation of text messages. The project will continue as long as it will

receive sufcient funding to do so, currently the project is nancially sustainable till October 2010.25

5.3 The High Cost of Access to eHealth Devices

The emergence of e- and mHealth applications throughout developing countries is now widely documented

and accepted. However, a critical component, the affordability of mobile services, continues to escape

those who require access to mobile technology, the global poor. As a result of price competition, the price

of a cellular handset and arguably calls, have reduced dramatically over the last decade. The International

Telecommunications Union (ITU) reports that by the end of 2008, there were more than 4 billion mobile activemobile subscriptions.26 Figure 5 provides an overview of the numbers used below.

For the countries selected in this work, affordable ICT among the masses is not a reality and the numbers

paint a bleak picture. Trinidad and Tobago ranked 23 (highest among chosen countries), among 150 coun-

tries polled by the ITU with respect to mobile affordability. Trinidad and Tobago spends approximately US$

7.9 a month on its basic mobile basketi, per the ITU. Large disparities occurred within this region, where

i Price reects the standard basket of mobile monthly usage in US$ determined by the OECD for 25 outgoing calls per month (on-net,

off-net and to a xed line), in predetermined ratios, plus 30 Short Message Service (SMS) messages.


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Peru for instance was ranked 79 and spent 2.8% of its Gross National Income (GNI) per capita toward mobile

services.ii That being said, Latin American economies selected for this paper, scored the highest in mobile

affordability against all other selected regions.

On average, the Vietnamese spent 6.4% of their monthly GNI toward mobile services and the country placed

110 on the ITU affordability scale. Its South Asian counterpart, India, was ranked 64. India was classed by

the ITU as having the most affordable basic mobile basket, at US$ 1.60 per month. Indians on average spent

2.1% of their monthly GNI on mobile services compared to Vietnams 6.4%.

Comparable inequalities existed in Eastern Europe between Estonia and TFYR Macedonia. The region had

the highest mobile basket cost of US$ 13.6 and US$ 13.2, respectively. Estonians however, spent only 1.2% of

their monthly GNI toward mobile services as opposed to Macedonians 4.6%.

The data for the African group of countries shows that they are by far performing the worst. South Africa

leads the group with a ranking of 73 and 2.6% of monthly GNI per capita, but Malawi, Tanzania and Ugandaare all ranked 148, 141 and 142 respectively; each country also spent 57.4%, 33.3% and 36.8% of GNI per

capita respectively on mobile subscriptions. Despite recent drops in prices, the initial and monthly costs of

owning a mobile phone remain out of reach for the majority of Ugandans who need them most. Given the

data presented above, this assertion can arguably be made for Malawi and Tanzania as well.

Other forms of eHealth devices are also challenged by high costs and lack of nancing is one of the biggest

threats towards the Baobab Project in Malawi, where the initial touch screens were cheap leftovers trans-

formed to the health service setting. These devices are currently not being produced anymore, and costs

have therefore increased signicantly, making it difcult to expand the project.

The private sector could play a big role in helping reduce the costs of e- and mHealth, i.e. to mobile hard-

ware and monthly subscription costs. For instance a system of cross subsidization using sales in the devel-

oped world, to help subsidize the cost of phones sold in the developing world could be implemented with

great success. Similarly, many telecommunications companies are transnational in nature and maintain

presence in wealthy, emerging and developing economies. The cross subsidy model could also be applied

using revenues from higher income countries to subsidize lower income mobile subscriptions.

The lack of funding remains a major barrier to the progress of eHealth, particularly in developing coun-

tries. Public funding is by far the most common source of nance. As government budgets are continually

stretched, eHealth must compete with other public services for its share of limited resources. In order to

garner such funds, governments must be convinced that money allocated to eHealth will not only improve

health services in the short-term, but will be a solid investment in the future of their nations health care

system. Provision of evidence-based eHealth project success stories and best practices would inform and

assist ministries with their bids for funding.

6. Role of Civil Society

Civil society can be dened as the link between the market and the state, and is also known as NGOs, non-

prot organizations or the social economy. It can include a variety of entities such as health clinics, family

ii The ITU considers less than 1% of GNI spent on mobile services as acceptable.


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counseling agencies, human rights organizations, universities, and grassroots development organizations.

A list of common features that they share includes: their character structured by private efforts, their inde-

pendence from the governmental apparatus, and their overarching objective which is to serve a public orcommunity purpose, not simply to generate nancial prots. Civil society organizations are committed to

freedoms and the right to act. The leading principle they follow is that people have responsibilities not only

to themselves but also to the communities they are part of.27

6.1 Civil Society and Health

Historically, civil society has played an important role in South Africa. The power of these institutions came to

play especially throughout Apartheid and especially in the later political battle about access to antiretroviral

medicine. Visible change in the countrys attitude towards the HIV epidemic is mostly due to the profound

pressure from non-governmental interest groups, which focus on creating a political environment that can

facilitate provision of treatments and resources as an essential response to this serious problem that has

plagued the country.28 This shows the profound potential of power civil society organizations posses.

In India civil society plays a profound role in the health sector where a booming private sector covers 80% of

total healthcare spending.29 This portrays a dire picture of the public healthcare system and it is within this

context that the role of civil society and health intersect. Ahead of general elections, in early 2009 more than

a thousand civil society organizations collaborated on designing a health manifesto for political parties.

The goal was to demand prioritization of pressing healthcare issues countrywide. This step undertaken by

NGOs in India was motivated by the signicant inequality in health with disparities in distribution between

rural and urban, poor and rich. The Government developed a National Rural Health Mission, however

politicians were criticized for not allocating sufcient funding and resources towards it.30 NGOs remain

important actors in generating attention to the resource allocation for healthcare services that must be

increased to Indias disadvantaged groups.

On the same note, Peruvian civil society groups and NGOs have pushed for health, trying to improve the ex-

isting health options in the country.31 They have had measurable success in improving health conditions for

youth, but a remaining topic of concern is NGOs involvement for health improvements for rural populations;

particularly indigenous people who have been neglected persistently. For example, Amnesty International

reports show that indigenous women in Peru have a much higher maternal mortality rate than the aver-

age Peruvian women, which is a consequence of absence of health facilities and health services target-

ing womens health in indigenous areas. This largely goes unnoticed by all parts of society, including civil

society.32 This shows the power of civil society and how it can give a voice to healthcare matters affecting

marginalized groups who are generally overlooked. At the same time, it shows limitations that civil society

doesnt necessarily cover all marginalized populations.

In Qatar for example, the role of NGOs is very limited, especially with regards to implementing ICTs forhealth. This is mainly caused by the fact that the Government has implemented a broadly based health

system that gives access to 100% of its citizens.33 Similarly, Estonian NGOs are not active participants of

decisions taken by the Estonian eHealth Foundation, but they are informed on a regular basis in order to as-

sist with awareness campaigns and implementation processes involving all stakeholders of society. NGOs

in Trinidad & Tobago34 play a comparable role where they have no say in decision-making programs. But

they are invited to participate in ICT readiness assessment projects, undertake ICT awareness campaigns

for wide usage of offered services, and encourage connectivity among different communities and different


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actors in the private and public spheres. Thus, well-coordinated national health systems and widespread

access to eHealth services limit the role of civil society to one that focuses on health advocacy or national

health program monitoring.

6.2 Involvement of Civil Society at the Program Level

In some of the featured case studies civil society was included, either directly in the project or through an

exchange of views before implementing the project. In South Africa, Project M was established in partner-

ship with multiple stakeholders, including civil society organizations. Targeted text messages were devel-

oped by a local educational NGO, and another partner was a national HIV/AIDS, non-prot helpline, provid-

ing anonymous, HIV counseling and referral that text receivers were directed towards.35 Call rates from the

helpline helped determine which topics required further attention. For example, phone-counselors found

that there was a great amount of misconception about prevention measures and mother to child transmis-

sion of HIV. Findings like these were used to develop more and better targeted text messages about each

topic of interest.36

In Uganda on the other hand, the TTC project had no formal contracts with local civil society organizations;

however, they did form the basis from which TTC designs its programs. For example, a local NGO supplying

HIV/AIDS counseling and testing was instrumental in providing local context to the general awareness and

prevalence of HIV/AIDS throughout the pilot program areas. Also, the software platform used to design the

TTC quizzes was using local services that were familiar with local dialect and customs, demonstrating the

importance of listening to the voices of those TTC would be serving.37

Even though the involvement of civil society has proved useful, not all of the featured projects have included

such organizations in their scope of work. For instance, in the e-Health system, providing training for health

workers in Qatar is fully implemented by the Government. However, with the context of Qatar in mind, civil

society simply has a limited role to play. Cooperation between all stakeholders is essential, but the role ofcivil society in ICT health projects is likely to be determined by the amount of government responsibility and

involvement in health issues.

7. Technical and Human Capital Constraints

A crucial component of ICT and Health programming in the developing world is the framework of infrastruc-

ture that supports these different initiatives. This infrastructure can consist of physical technology- such as

ber optics, cell towers, broadband or satellite connections to initiate tele-surgery or tele-consultations- or

it can be organizational, i.e. being bound by legislative, legal and/or bureaucratic constraints. They can also

be cultural, for instance if a population views ICT in a negative context and is averse to using it. Figure 6 and

7 show statistics on access and constraints regarding ICT use in the selected countries.If this infrastructural foundation is already in place, then often the quality is inadequate or sub-standard. For

instance what is termed high speed internet access in much of sub-Saharan Africa is considerably slower

and more expensive than internet access in say that of India.38 In East Africa, Tanzania or Ethiopia, the cost

of ICT is a major obstacle in its implementation. Despite considerable developments in the ICT sector in

Africa over the past 10 years, the region has the worlds lowest and most expensive telephone and Internet

user penetration and quality of service.39


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Malawi is a classic case of ICT in Sub-Saharan Africa. The Malawian Government is committed to using

ICT in health; however, it is plagued by infrastructural challenges such as a narrow industrial base or an

unstable and intermittent power supply. As far as human resources challenges, they are also hindered byan insufcient amount of qualied professionals to assist in ICT integration in rural areas, unregulated ICT

training facilities and low awareness levels of ICT as a method for economic development.40

On the opposite end of the spectrum, countries such as Qatar, Uganda, Vietnam and South Africa all anchor

their respective regions in telecommunications and expansion of ICT infrastructure that can be used in

eHealth. Vietnams ICT growth rate was double that of average in the Asia region and triple that of the world

average in 2006.41 South African telecom company MTN provides mobile broadband throughout the entire

country of Uganda and back in its native country, 90% of South Africans have access to a mobile device.42

Qtel, which used to be Qatars sole public telecom company, introduced such mobile technological inno-

vations as DVBH (Digital Video Broadcasting- Handheld) service to the Middle East, delivering real-time

mobile TV broadcasts that capture satellite television channels and play them through mobile handsets.43 Italso introduced 3G mobile internet and video calling, as well as a service called TETRA (Terrestrial Trunked

Radio), which is a professional two-way radio system for companies and organizations such as government,

oil and gas, police, defense, security, public safety, paramedic and the private sector.44 It has massive po-

tential in terms of supporting eHealth initiatives.

It is as a direct result of these types of technological innovations that India leads its region in ICT and health

collaborations- which boast some of the most advanced technologies available and serve marginalized and

under-serviced communities.45

Outside of these physical, technological constraints are human capital constraints such as brain drain, skills

and existing capacity among others. In places where this technology has not yet become standard, training

in ICT is inadequate and costly to implement if people are not familiar with it. The adjustment to new technol-ogy can be hard to implement as well as time consuming and not cost-effective.

The concept of Brain Drain, the emigration of individuals with advanced and/or specied technical knowl-

edge or skill-sets due to political or economic instability, can signicantly contribute to this as well. Places

such as India and South Africa, have traditionally had a serious problem with keeping human resources

(highly talented, skilled, trained physicians, etc.) and those they do keep, are usually lured to private institu-

tions by larger salaries that a state-run facility could not compete with.

8. Monitoring and Evaluation

Monitoring and evaluation plays a pivotal role in any project acting as the listening device as to whether

any initiative is meeting its stated goals and objectives. In this section, it will be examined how selected ICTinitiatives have worked to complement as well as develop the health sector in featured countries.

The evaluation of the ICT projects in these countries reveal that heightened linkages in the ICT and health

sectors, in both middle-income and low-income countries, works to dismantle cultural taboos, share knowl-

edge among populations through faster dissemination of information about important health topics.


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8.1 Easy Use of PDAs

In Peru, the Colecta-PALM project demonstrated that using PDAs was useful in developing countries whereindividuals were not accustomed to regular usage of similar devices. The survey participants were open

to not only using the device but also to receiving follow-up messages specic to their individual cases in

order to prevent the spread of HIV/AIDS. Out of the total number of participants, 74% agreed to work with

the PDAs, each of whom completed a survey on the device.46

Current evaluation of the CA:SH system in India indicates high acceptance of the technology and reduction

in total time for entry of data. An evaluation of the ve-month pilot, indicated high acceptance of the tech-

nology and reduction in total time for entry of datathe [health workers] were satised with the user inter-

face and were able to depend entirely on the handheld, replacing their existing paper-based records.47

8.2 Cracking Health Stigmas

IBM is currently analyzing the data collection for TTC in Uganda and the data and opinions are then dis-seminated to larger health agencies across the country. One big lesson learned by TTC was that most

participants did not believe HIV/AIDS tests were accurate or anonymous. This information was rapidly com-

municated to larger health actors in hopes that they could do more to begin dispelling these public myths.

Project M in South Africa is the worlds largest eld trial of mHealth and it has been designed to serve as

a scalable, high-impact model that can be replicated worldwide. Since October 2008 the project has sent

out almost 300 million SMS messages to the general public on HIV/AIDS and TB, which have resulted in

1,060,000 calls to the national AIDS hotline, representing a 0.38% average response yield. There has been a

300% increase in call center volume since the launch, and a greater increase in calls are seen when messages

are seen in vernacular languages such as Zulu, compared to when sent in English. Also, when messages

are targeted at women, a higher return call rate of women is achieved. It is especially encouraging that

more young men are responding, as they have previously been difcult to reach.48

8.3 Shorter Wait Times for Patients

In Malawi, before the Baobab system was introduced, patients would stand in line for hours, because of

the exhaustive administrative process that comes with lling out health information. With the new touch

screen based system, registration time is down to under a minute for new patients and less than 10 seconds

for returning patients. Currently, the total number of registered patients by Baobab (bar-coded patients) is

1,095,000 and the total antiretroviral patients captured under this scheme number 37,500.49

8.4 Medical Data Collection and Country Staff Development

A Baobab pilot study in the pediatric Hospital in Malawi, showed that computer-based entry can be suc-

cessfully deployed and used in resource poor settings, it can be sustained at relatively low costs and withlocal resources, and has a greater potential to improve patient care in developing countries. The introduc-

tion of the system has eliminated errors in medication dosage by improving documentation.

The touch screens help improve the accuracy of clinical data gathering. The data is being used on a national

level where the electronic data reports are used to forecast and plan HIV delivery in Malawi.

In Qatar the Supreme Council of ICT monitors the progress of its e-Health system. The impact of the e-Health

system has combined all stakeholder efforts in the sector through a systematic, country wide medical cod-


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ing system and online terminology database that links all regions of the country together. The e-Health

system has also produced a certied online training program that is available to all emergency room and

nursing sector health care workers, in order to encourage e-Literacy. The Qatari Supreme Council of ICTshould push to require all government health care workers to complete this e-Literacy training program.

8.5 ICT for Health Education

The Jordanian government has studied whether the Knowledge Station centers are placed in the right

areas of the country and if the nancing is sustainable. The studies have concluded that the Knowledge

Stations have succeeded in targeting key marginalized populations and improving their knowledge of com-

puter literacy by training 102,324 people, 56% of them being women. Knowledge Centers have allowed dis-

enfranchised populations to access basic health ICT resources and be informed about overarching health

concerns. Statistics reveal that women outnumber the number of men trained using the Knowledge Stations

by 12%, which is an important step towards targeting gender discrimination and educating the marginalized

populations in Jordan.

9. Lessons Learned

Based on the featured ICT initiatives and individual country efforts, this segment takes a broad look at some

of the key lessons learned when implementing eHealth. The lessons here focus in particular on nancial

sustainability of projects, language barriers during and after implementation, as well as the increased role

civil society can play.

Readers should note that these lessons learned are formed largely based on the experiences of the chosen

countries and technologies and do not represent an all encompassing list of challenges faced across the

sector. The following section, will attempt to harmonize these lessons into actionable recommendations to

be adopted across all initiatives.

9.1 Financial Sustainability of ICT Projects

In Jordan, the future success of the Knowledge Stations project will depend on the ability of the government

to sustainably fund the centers, without requiring an out-of-pocket expense to be paid by citizens.

Research needs to be undertaken by the government and its multitude of funders in order to see if the

health seminars and workshops offered by the Knowledge Stations are effective. To address its viability, a

nationwide rubric for rating the health education received (in partnership with station owners), and perhaps

a standard curricula, could be introduced to address the health needs of marginalized populations across

regions of the country.

In both Vietnam and India, applicable government ministries need to be able to make budget allocationsin proportion to the scale of the economies and fasttrack legislation to make eHealth initiatives legal and

lawful. Without these allocations, both monetary or political, civil society and the private sector will nd

themselves powerless and ineffective as far as facilitating real change.

The Baobab system in Malawi has a nancial drawback as well. The original touch screen hardware is no

longer produced and current touch screens are US$ 700 per device, which proves extremely expensive, and

could become a roadblock for the nancial sustainability of the Baobab system.


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Project M in South Africa made text messages free of charge; however the next step in the project to

call the national AIDS hotline was only free when calling from a landline. Mobile callers are charged at

standard mobile rates and with 95% of the population being on pre-paid or pay-as-you-go this is relativelyexpensive. The increase of the volume of calls to the Helpline show that people are willing to pay for the

service, however, more people could be reached if the service was free. Pressure is needed on the mobile

operators to collaborate and set up a toll-free line for HIV/AIDS counseling.

9.2 Lack of English Skills and Education as a Road Block to ICT

The Baobab system in Malawi is based in English and requires the healthcare worker to have English read-

ing and writing skills. Not tailoring software to be exible to local languages has affected take-up of tech-

nologies as not all healthcare workers have the requisite language skills.

In South Africa on the other hand, Project Ms text messages are written in local languages and therefore

reach more people. South Africa has eleven ofcially recognized languages, and in order to reach as manypeople as possible, it is crucial that people are being targeted using a language they can understand.50 This

is a positive example that the Malawi Baobab system should try to replicate.

9.3 Effective Counseling against Stigmas

The targeted method of outreach used in Project M in South Africa is more effective than traditional methods

used when trying to convince people to get counseling. Receiving information by text messages offers a more

intimate alternative to traditional methods and thus lowers stigmatization of HIV/AIDS. This is evidenced by the

high rate of users within the Project M system. In addition, Project M is working to create health test kits that

can be used at home, so that patients can test themselves in the privacy of their homes.

It was noted in Tanzanias e-IMCI program that not all clients who visited the clinicians were comfortable

with the doctor using a PDA rather than speaking to them directly. Though this was largely cultural and raregiven the overwhelming approval of the device, it should be noted that some experienced discomfort with

their personal data being entered into a device rather than being written down. Here again, room should be

made in the software and e-IMCI protocols to allow the health worker to set the device down and continue

the session without the PDA.

9.4 ICT for Health, Technical and Human Capacity

A challenge has been to increase the capacity of the call centers that handle the phone calls. Staff behind

Project M hopes to supplement employees at local call centers with off-site, trained HIV positive counsel-

ors, which would both create jobs and increase the capacity of the health response. This step would be

critical for the launch of the free at-home testing kits, which cannot be implemented before an easy-to-

reach network of counselors has been established.

51

Patience is critical to working in Uganda and arguably, Africa. Things move at a slower pace and projects often

encounter hurdles during and after the implementation cycle. To establish a xed line connection takes several

days in Uganda and although the timeline for acquiring a mobile line has been reduced, it is by no means quick.

Technology will not solve all issues: a lesson learnt during the e-IMCI trials. What the designers realized in

Tanzania, is the inherent need for a balance between speed and efciency while maintaining exibility and

allowing the physician, not the tool, to determine the best course of action.


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organizations, private development contractors, academia and the government. Obviously, all of these ac-

tors will not be a part of every ICT/Health program or initiative happening in each country, sometimes only

two or three at a time will be involved. However, each actor should make it easier for the others involvedwith it, in order to facilitate maximum services rendered to the largest group of beneciaries.

10.1 For Governing bodies

National Governments should recognize the signicant impact ICT can have on the health sector and

make reasonable allocations for the sector. A clearly dened national ICT plan aimed at the health

sector should be a key priority.

National and local governments should encourage involvement and contributions of civil society

and private entrepreneurs. This can be done through legislation, if there are laws complicating NGO/

private partnerships, or by offering incentives, perhaps tax-based, to both parties, making partner-

ship more appealing. Governments should liberalize their ICT markets to allow competition and thusreduce costs of ICT.

Bridging the urban/rural divide in countries across the global South must remain at the forefront of

any government initiated health efforts. Governments must make bolder strides to ensure increased

equity and access to basic health services in the rural segments of their countries.

Countries that are making use of ICT in other sectors should make efforts to implement and further

develop these initiatives to suit the health sector.

10.2 For International Organizations and Donors

Some countries lack sufcient funds to make ICT their top priority and are thus dependent on exter-

nal assistance. Contributions should be earmarked to ensure that a share goes toward ICT in health.

Recipient governments should be held accountable, ensuring international dollars are wisely spent.

International organizations should foster active participation from local civil society organizations. They

have critical on the ground insights that prove invaluable and always suited to the cultural context.

Efforts from the international community to increase use of ICT in health are fragmented, a more

targeted and coherent approach should be developed, where the UN plays a key role in monitoring

and coordination.

10.3 For Civil Society

Civil society should apply pressure on the state health apparatus and private sector to employ ICT

in Health initiatives. Promoting partnerships is a key point, as civil society groups have the unique

qualications to act as interlopers between different private and state interests.

In countries where national health systems are relatively well functioning, civil society still has a role

in advocacy and monitoring of health issues. This is especially important to ensure improvements for

rural and more vulnerable parts of a population.

10.4 For Private Entrepreneurs

Private entrepreneurs must be encouraged to participate in introducing ICT for health in developing

and transitional countries. There are many ways in which a telecom company can facilitate eHealth


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11. Appendix

Figure 1: Featured ICT Initiatives

Albania - eHealth Policy and Legislature: Between 2001 and 2004 national mechanisms such as aninformation policy, an eStrategy, and an eHealth policy were adopted to Albanias national health plan. With

the support of the Ministry of Health, the country plans to implement procurement policies and strategies

to guide software, hardware and content acquisition in the healthcare sector. The Ministry of Health also

provides resources towards the professional development of Albanias healthcare workforce in ICT.53

Estonia - eHealth Projects: In October 2005, Estonias Ministry of Social Affairs, with support by the Euro-pean Union (EU) Structural Funds and in collaboration with a team of national partners, initiated the eHealth

Foundation. The core objective of this project incorporates: development of a structured framework for

eHealth architecture; management of electronic health records and setting the stage for digital prescrip-

tions, digital registrations, and digital images. eHealth in Estonia was created by employing existing IT infra-structure while also conducting research for system and service improvements.54

India - Community Accessible and Sustainable Health System (CA:SH): The CA:SH program startedin 2002 and was designed to address the problems of poor data ow and logistical support for rural medical

workers in the State of Haryana, India. A handheld software application to facilitate ordered data collection,

immunization scheduling, pre-natal care for pregnant mothers and recording routine demographic changes

in the community was developed.55

Jordan - Knowledge Stations: In an effort to bridge the gap between marginalized populations and ICT,the government started drawing plans for Knowledge Stations in 2001. These stations are centers where

women, children, the poor and rural populations can go to gain cheap access to Internet, computers, copy

and fax machines, as well as computer training courses. These Knowledge Stations facilitate learning

about and having access to a number of social needs, health information being one.56

Macedonia - Telemedicine Project: Evaluating requirements and qualications for a basic Medical In-formation System (MISs) was the main goal of this project. Development of a structured framework and

user-friendly interfaces made it possible for multiplatform MISs to interconnect in an integrated MIS. This

project makes it possible for Macedonian hospitals to: share knowledge, experience, and expertise to be

shared among healthcare providers; have real time consultations for patients including those in remote

areas through video streaming making access to medical information easy, quick, and affordable to all

interacting participants.57

Malawi - Baobab: To support rural health workers and lead them through treatment and diagnosis, Bao-bab applies easy-to-use touch screen clinical workstations at Malawian hospitals and HIV clinics. By using

inexpensive, low-power touch screen computers (TCW) and applying the model of care, developed by theMinistry of Health in Malawi, the touch screens guide low-skilled health workers through the diagnosis and

treatment of patients. Furthermore, the system allows real-time, statistical monitoring and studying of health

data, helping to focus and efciently target HIV treatment programs. The data is being aggregated and used

at a national level for policy making and analysis.58

Peru - Colecta-PALM: The Colecta PALM program was implemented to assist people with HIV/AIDS. Thisprogram used was an open sourced and secured web-based application in Spanish that gave surveys to


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the participants. These surveys helped project administrators collect data about the participants using

Personal Digital Assistants (PDAs). The surveys monitored how the patients were using medications and

practicing safe sex to keep them from transmitting HIV/AIDS to others. The program provides feedback tothe participant to encourage responsible behavior so as not to spread the disease.59

Qatar - ictQATAR: The Qatar government has proposed modern and sophisticated nancing for healthplans that are geared toward the advancement of information and communication technologies. The e-

Health Strategy is a health plan with an emphasis on ICTs or health that is being developed by 2010. The

goals are that users of the e-Health system will have widespread access to information, services and health

products via Internet, and the system will have the capacity to monitor chronic health situations, such as a

diabetes patients blood sugar levels.60

South Africa - Project Masiluleke (Project M): Project M operates by using mobile technology to bringpeople with HIV and tuberculosis into the healthcare system earlier and thereby increase chances of liv-

ing longer and healthier lives. The project was started in 2008, and uses specially developed open sourcesoftware to send millions of targeted health messages to mobile phone users in the country. The messages

describe symptoms of HIV and encourage mobile users to contact existing HIV and Tuberculosis (TB) call

centers where trained operators provide health information, counseling and referrals to local testing clinics.

The project also keeps patients with AIDS connected to care by reminding them of scheduled clinic visits

and thereby ensuring they adhere to antiretroviral regimens.61

Tanzania - e-IMCI: e-IMCI was launched to overcome manual and scal healthcare barriers. It is a pro-gram that essentially runs to protocol Integrated Management of Childhood Illness (IMCI) on a PDA and

guides health workers thorough the IMCI protocols. Since the software automatically guides health workers

through the IMCI algorithms, there is less human error and greater adherence.62 63

Trinidad and Tobago - Virtual Health Library (VHL): Trinidad and Tobago has implemented VHL, whichtakes health information for the country and organizes it in a structured manner. Users can access the VHL

from any location with internet-access. It is easy to use, and breaks information sections into categories

such as AIDS, Asthma, Breast Cancer, etc.64

Uganda - Text to Change (TTC): In late 2008, Text to Change was launched as a tool to help spread aware-ness about the effects of HIV/AIDS in Mbarara, Uganda. The program aimed to use mobile phones for HIV

education and encouraged the public to voluntarily seek HIV testing and counseling services. Using SMS

technology, TTC provided HIV/AIDS awareness testing via quizzes sent to 15,000 mobile subscribers during

three months of testing. As an incentive to participate, free airtime was provided to users. This proved criti-

cal since users can exchange the airtime with others as a form of mobile currency.65

Vietnam - The Remote Interaction, Consultation and Epidemiology (RICE) system: The RemoteRICE system is a cellular phone-based electronic medical record designed to facilitate remote medi-cal consultation, epidemiological surveillance and access to medical knowledge for populations without

access to computers or the internet. Rural locals are always at an elevated risk during communicable

disease outbreaks and Southeast Asia was previously identied as a potential high-risk area for SARS

and Avian inuenza transmission.66


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Figure2:Progressonthe

MDGs

MDG4

MDG5

MD

G6

Infantmorta

lity

rate(0-1yea

r)

per1,0

00liv

e

births.

Childrenunder

vemortal-

ityrateper1,0

00

livebirths.

Proportionof1

yearoldchil-

drenimmu-

nizedagainst

measles(%).

Maternal

mortalityratio

per100,0

00live

births

Birthsat-

tendedby

skilledhealth

personnel

(%).

Peo

pleliving

withHIV,

15-24

yea

rs(%).

Tuberculosis

deathrate

peryearper

100,0

00popu-

lation

Childrenu

nder

5sleeping

un-

derinsect

i-

cide-treat

ed

bednets(%).

Albania

1990

37

1990

46

1990

88

N/A

2000

99

N/A

1990

4

N/A

2007

13

2007

15

2007

97

2005

92

2005

99

N/A

2007

3

N/A

Estonia

1990

14

1990

18

1993

74

N/A

1992

99

20

01

0.5

1990

4

N/A

2007

4

2007

6

2007

96

2005

25

2006

100

20

07

1.3

2007

6

N/A

India

1990

83

1990

117

1990

56

N/A

1993

34

20

01

0.5

1990

42

N/A

2007

54

2007

72

2007

67

2005

450

2006

47

20

07

0.3

2007

28

N/A

Jordan

1990

33

1990

40

1990

87

N/A

1990

87

N/A

1990

1

N/A

2007

21

2007

24

2007

95

2005

62

2007

99

N/A

2007

1

N/A

Macedonia

1990

33

1990

38

1993

98

N/A

1990

89

N/A

1990

11

N/A

2007

15

2007

17

2007

96

2005

10

2006

99

N/A

2007

5

N/A

Malawi

1990

124

1990

209

1990

81

N/A

1992

55

20

01

13

1990

62

2000

3

2007

71

2007

111

2007

83

2005

1100

2006

54

20

07

12

2007

102

2006

23

Peru

1990

58

1990

78

1990

64

N/A

1992

53

20

01

0.4

1990

34

N/A

2007

17

2007

20

2007

99

2005

240

2006

71

20

07

0.5

2007

16

N/A

Qatar

1990

20

1990

26

1990

79

N/A

1996

98

N/A

1990

6

N/A

2007

12

2007

15

2007

92

2005

12

N/A

N/A

2007

7

N/A

SouthAfrica

1990

49

1990

64

1990

79

N/A

1995

82

20

01

17

1990

78

N/A

2007

46

2007

59

2007

83

2005

400

2003

92

20

07

18

2007

230

N/A

Tanzania

1990

96

1990

157

1990

80

N/A

1992

44

20

01

7

1990

43

1999

2

2007

73

2007

116

2007

90

2005

950

2005

44

20

07

6

2007

78

2007

57

Trinidad&

Tobago

1990

30

1990

34

1990

70

N/A

1997

99

20

01

1.4

1990

2

N/A

2007

31

2007

35

2007

91

2005

45

2006

98

20

07

1.5

2007

2

N/A

VietNam

1990

40

1990

56

1990

88

N/A

1997

77

20

01

0.3

1990

33

2000

16

2007

13

2007

15

2007

83

2005

150

2006

88

20

07

0.5

2007

24

2006

5

Uganda

1990

106

1990

175

1990

52

N/A

1995

38

20

01

8

1990

69

2001

0.2

2007

82

2007

130

2007

68

2005

550

2006

42

20

07

5

2007

93

2006

10

Source:MillenniumDevelopme

ntGoalsIndicators:TheOfcialUnitedNationsSitefortheMDGIndicators,r

etrieved

from:


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mHealth Telemedicine

Denition

The delivery of health-related services via mobilecommunications technology Health-related services delivered remotely with clini-cal participation

Distinctions

mHealth implies the use of solutions and services de-signed to be accessed and delivered via cellular orwireless broadband networks

Implies technology to provide patient/clinician interac-tion real-time using multiple ICT (i.e. video, IP, voice)

Examples

Mobile access to health records Patient monitoring

Public health alerts, monitoringNutrition awareness programs

Training and support for rural health workers

Medication monitoring

Outbreak tracking and reporting

Behavior change, education and awareness program

Remote health clinics

Remote diagnostics and consultationRemote support for local health care provider

Source: Vital Wave Consulting, mHealth in the global South Landscape Analysis, 2008.

Low Complexity of eHealth applications High

Figure 3: Positioning eHealth, mHealth and telemedicine

Education/

Awareness

Monitoring/

Compliance

Data

Access

Disease /EmergencyTracking

HealthInformationSystems

Diagnosis /

Consultation


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22 | WHITE PAPER

Figure4:Countryhealthe

xpenditures

Total

expendi-

tureo

n

healthas%o

f

gross

dome

stic

produ

ct

Generalgovern-

ment

expenditureon

health

as%o

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expenditure

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Private

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n

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s%o

f

total

expenditure

onhealth

Externalre-

sourcesfor

healthas%

oftotal

expenditureon

health

Out-of-pocke

t

expenditureas%

ofprivate

expenditureon

health

Percapita

government

expenditure

onhealth

(PPPint.$)

Percapita

government

expenditure

onhealth

ataverageex

-

change

rate(US$)

2000

2006

2000

2006

2000

2006

2000

2006

2000

2006

2000

2006

2000

2

006

Albania

6.4

6.5

36.3

37.3

63.7

62.7

6

3.5

99.9

94.9

87

142

27

70

Estonia

5.3

5.2

77.5

73.3

22.5

26.7

0.9

0.6

88.5

93.3

404.0

702.0

169.0

464.0

India

4.3

3.6

21.8

25.0

78.2

75.0

0.6

1.0

92.1

91.4

14.0

22.0

4.0

7.0

Jordan

9.4

9.7

46.5

43.3

53.5

56.7

4.6

4.7

74.7

75.9

141.0

188.0

77.0

103.0

Macedonia

7.6

8.0

70.9

70.6

29.1

29.4

3.2

1.1

100.0

100.0

334.0

444.0

96.0

176.0

Malawi

6.1

12.9

43.8

69.0

56.2

31.0

26.9

59.6

42.4

28.4

17.0

43.0

4.0

1

4.0

Peru

4.7

4.4

53.0

58.3

47.0

41.7

2.0

1.5

79.4

77.5

123.0

184.0

52.0

8

7.0

Qatar

2.3

4.3

68.8

78.2

31.2

21.8

0.0

0.0

84.5

88.2

866.0

454.0

21

57.0

SouthAfrica

8.1

8.0

42.4

37.7

57.6

62.3

0.3

0.9

18.9

17.5

220.0

270.0

100.0

160.0

Tanzania

3.9

6.4

40.4

57.8

59.6

42.2

26.7

43.9

80.0

54.3

12.0

42.0

4.0

1

3.0

TrinidadandTobago

3.9

4.4

42.8

56.5

57.2

43.5

4.7

2.4

86.3

88.0

104.0

339.0

Uganda

6.6

7.0

26.8

25.4

73.2

74.6

28.3

31.2

56.7

51.0

12.0

18.0

4.0

6.0

Vietnam

5.4

6.6

30.1

32.3

69.9

67.7

2.5

2.2

91.7

90.2

23.0

49.0

6.0

1

5.0

Sweden

8.2

9.2

84.9

81.7

15.1

18.3

0.0

0.0

91.1

87.9

1938.0

2853.0

1936.0

32

45.0

UnitedStates

13.2

15.3

43.7

45.8

56.3

54.2

0.0

0.0

26.6

23.5

1997.0

3076.0

1997.0

30

76.0

Averages

5.7

6.7

46.2

51.1

53.8

48.9

8.2

11.7

76.5

73.1

187.8

191.3

84.7

277.8

Asia

4.9

5.1

26.0

28.7

74.1

71.4

1.6

1.6

91.9

90.8

18.5

35.5

5.0

1

1.0

Africa

6.2

8.6

38.4

47.5

61.7

52.5

20.6

33.9

49.5

37.8

65.3

93.3

28.0

4

8.3

Mid-East

5.9

5.9

57.7

57.7

42.4

42.4

2.3

2.3

79.6

79.6

503.5

503.5

265.5

265.5

EastEurope

6.5

6.6

74.2

72.0

25.8

28.1

2.1

0.9

94.3

96.7

369.0

573.0

132.5

320.0

Americas

4.3

4.4

47.9

57.4

52.1

42.6

3.4

2.0

82.9

82.8

123.0

184.0

78.0

213.0

DevelopedRegions

10.7

12.3

64.3

63.8

35.7

36.3

0.0

0.0

58.9

55.7

1967.5

2964.5

1966.5

31

60.5

Source:WorldHealthOrganiza

tion,W

orldHealthStatistics2009,r

etrieved

from:http://apps.w

ho.in

t/whosis/data/Sea

rch.js

p?countries=

[Location].

Members,

October2009.


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WHITE PAPER | 23

Figure 5: ICT basket prices

ICT Price BasketValue 2008 out of 150

countries

Mobile Sub-basketranking 2008 out of 150

countries

Mobile sub-basket as a% of monthly GNI

Mobile sub-basket(US$)

Albania 7.1 115 8.3 22.7

Estonia 2 42 1.2 13.6

India 4.7 64 2.1 1.6

Jordan 6.1 60 1.9 4.5

Macedonia 4.2 99 4.6 13.2

Malawi 57.8 148 57.4 12

Peru 6.9 79 2.8 8

Qatar N/A N/A N/A N/A

South Africa 4.2 73 2.6 12.3

Tanzania 55.4 141 33.3 11.1

Trinidad and Tobago 1.1 23 0.7 7.9

Uganda 60.4 142 36.8 10.4

Vietnam 11.9 110 6.4 4.2

Source: International Telecommunication Union, Measuring the Information Society - the ICT Development Index, 2009.

Figure 6: Ranking according to the ICT Development Index of 154 countries

2002 2007

Albania 93 85

Estonia 31 26

India 117 118

Jordan 65 76

Macedonia 53 65

Malawi 141 141

Peru 71 74

Qatar 47 44

South Africa 77 87

Tanzania 138 145

Trinidad and Tobago 58 56

Uganda 143 140

Vietnam 107 92

Source: International Telecommunication Union, Measuring the Information Society - the ICT Development Index, 2009.


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Figure 7: ICT Access, Usage and Skills ranking

2002 2007 2002 2007 2002 2007

Albania 78 96 130 78 92 78

Estonia 37 24 20 27 18 21

India 124 129 57 44 118 118

Jordan 66 78 70 75 50 60

Macedonia 72 55 46 50 64 63

Malawi 145 138 143 144 132 136

Peru 94 85 59 61 51 56

Qatar 41 39 57 44 84 79

South Africa 77 84 67 92 80 80

Tanzania 121 140 144 143 139 142

Trinidad and Tobago 50 47 55 67 87 92

Uganda 150 142 132 126 134 133

Vietnam 118 90 105 74 95 102

Source: International Telecommunication Union, Measuring the Information Society - the ICT Development Index, 2009


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List of Acronyms

AIDS Acquired Immune Deciency Syndrome

CA:SH Community Accessible and Sustainable Health System

DVBH Digital Video Broadcasting- Handheld

EU European Union

eHealth Healthcare Service by Electronic Devices & Information Exchange

e-IMCI Electronic Integrated Management of Childhood Illness

FYROM Former Yugoslav Republic of Macedonia

GDP Gross Domestic Product

GNI Gross National Income

HIV Human Immunodeciency Virus

IBM International Business Machines Corporation

ICT Information and Communication Technologies

ICT4D Information and Communication Technologies for Development

IT Information Technology

ITU International Telecommunication Union

MDGs Millennium Development Goals

mHealth Mobile Health

MIS Medical Information Systems

MMR Maternal Mortality Ratio

MTN South African Telecom Company

NGO Non Governmental Organization

NHRM National Health Rural Health Mission in India

OECD Organization for Economic Cooperation and Development

PDA Personal Digital Assistant

Project M Project Masiluleke

Qtel Qatar Telecom Company

RICE Remote Interaction Consultation and Epidemiology System

SMS Short Message Service or Silent Messaging Service

SARS Severe Acute Respiratory Syndrome

STDs Sexually Transmitted Diseases

SWAp Sector Wide Approach

TB Tuberculosis

TCW Touch Screen Computers


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TETRA Terrestrial Trunked Radio

TFYR Macedonia The former Yugoslav Republic of MacedoniaTTC Text to Change

UN United Nations

UNGAID Global Alliance for ICT and Development

VHL Virtual Health Library

WHO World Health Organization


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End Notes

1 McNamara, K. 2007. Improving Health, Connecting People: The Role of ICTs in the Health Sector ofDeveloping Countries. infoDev Working Paper No. 1 2007. Washington, DC, infoDev.

2 Global Alliance for ICT and Development. 2009. What is GAID? New York. Posted at: http://www.un-

gaid.org/About/tabid/861/language/en-US/Default.aspx

3 Vital Wave Consulting. 2008. mHealth in the Global South Landscape Analysis. Palo Alto, Vital Wave

Consulting.

4 World Health Organization. 2004. eHealth for Health-care Delivery: Strategy 2004-2007. Geneva, World

Health Organization. Posted at www.who.int/eht/en/EHT_strategy_2004-2007.pdf

5 Daly, J. 2003. Information and Communications Technology Applied to the Millennium Development

Goals. Washington, DC, Development Gateway Foundation. Posted at: http://topics.developmentgate-way.org/ict/sdm/previewDocument.do~activeDocumentId=840982

6 Ministry of Foreign Affairs Denmark. 2005. Good ICT Practice Lessons Learned in Health Sector. Co-

penhagen. Posted at: http://goodictpractices.dccd.cursum.net/client/CursumClientViewer.aspx?CAID=2

14113&ChangedCourse=true

7 World Bank. 2003. ICT and MDGs: A World Bank Group perspective. World Bank Working Paper No.

27877. Posted at: http://www-wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64

187937&theSitePK=523679&menuPK=64187510&searchMenuPK=64187283&siteName=WDS&entityI

D=000090341_20040915091312

8 Mingues, M. 2003. Information and Communications Technologies & the Millennium Development

Goals. Geneva. Posted at http://www.itu.int/ITU-D/ict/publications/wtdr_03/material/ICTs%20&%20MDGs.pdf

9 Vital Wave Consulting. 2009. mHealth for Development: The Opportunity of Mobile Technology for

Healthcare in the Developing World. Washington, DC and Berkshire UK, UN Foundation-Vodafone

Foundation Partnership.

10 Vital Wave Consulting. 2008. mHealth in the Global South Landscape Analysis. Palo Alto, Vital Wave

Consulting.

11 Ministry of Health, Uganda. 2009. Health Sector Strategic Plan II. Uganda, Ministry of Health. Posted

at: http://www.who.int/rpc/evipnet/Health%20Sector%20Strategic%20Plan%20II%202009-2010.pdf

12 United Nations Population Fund. 2009. Peru. New York, NY. Posted at: www.unfpa.org/webdav/site/global/shared/CO.../Peru_b2_9.23.doc

13 Ibid.

14 The United Republic of Tanzania Ministry of Health and Social Welfare. 2008. Health Sector Strategic

Plan III 2009-2015, Partnership for Delivering the MDGs. Tanzania, Ministry of Health. Posted at: http://

www.moh.go.tz/documents/Health_Sector_Strategic_Plan_III.pdf

15 Chopra, Mickey, et al. Achieving the Health Millennium Development Goals for South Africa: Challeng-

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