ICT in Health for Development - United Nationsunpan1.un.org/intradoc/groups/public/documents/un-dpadm/unpan...ICT in Health for Development A white paper commissioned by: ... priorities

ICT in Health for Development

A white paper commissioned by: UNDESA-GAID

December 2009 Group Members: Andrea Bordé, Charles Fromm, Farzad Kapadia, Doriana S. Molla, Eleece Sherwood and Jane Brandt Sørensen Advisor: Ambassador Rafat Mahdi


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TABLE OF CONTENTS: 1. INTRODUCTION........................................................................................... 4 2. INTERSECTION OF HEALTH AND ICTs...........................................................

5 3. ICTs AND THE MDGs...................................................................................

5 3.1 eHealth and mHealth: Challenges and

Opportunities................................... 6 4. ROLE OF GOVERNMENTS FOR IMPROVED HEALTH.....................................

7 4.1 National Health Plans..............................................................................

7 4.2 Innovative Health Plan Initiatives..............................................................

9 4.3 National Health Care Budgets...................................................................

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

9 5.1 Health Expenditure Analysis......................................................................

10 5.2 Public-private Partnerships for eHealth.......................................................

11 5.3 The High Cost of Access to eHealth

Devices.................................................. 12 6. ROLE OF CIVIL SOCIETY................................................................................

14 6.1 Civil Society and Health.............................................................................

14 6.2 Involvement of Civil Society at the Program

Level......................................... 15 7. TECHNICAL AND HUMAN CAPITAL CONSTRAINTS.........................................

16 8. MONITORING AND EVALUATION..................................................................

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8.1 Easy Use of PDAs....................................................................................... 17

8.2 Cracking Health Stigmas............................................................................. 18

8.3 Shorter Wait Times for Patients................................................................... 18

8.4 Medical Data Collection and Country Staff Development................................ 18

8.5 ICT for Health Education............................................................................. 19

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

19 9.1 Financial Sustainability of ICT Projects......................................................... 20 9.2 Lack of English Skills and Education as a Road Block to

ICT............................. 20 9.3 Effective Counseling against Stigmas........................................................... 21 9.4 ICT for Health – Technical and Human

Capacity............................................ 21 9.5 Reluctance of Governments and Private

Companies...................................... 22 9.6 Medical miss-diagnoses Using ICT............................................................... 22 9.7 Role of Civil Society and Public-Private

Partnerships...................................... 22

10. RECCOMENDATIONS......................................................................................... 23

10.1 For Governing bodies................................................................................. 23 10.2 For International Organizations and Donors................................................. 23 10.3 For Civil Society......................................................................................... 24 10.4 For Private Entrepreneurs........................................................................... 24 10.5 When Implementing ICT for Health.............................................................. 24

11. APPENDIX........................................................................................................ 25


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Figure 1........................................................................................................... 25 Figure 2........................................................................................................... 28 Figure 3........................................................................................................... 29 Figure 4........................................................................................................... 30 Figure 5........................................................................................................... 31 Figure 6........................................................................................................... 31 Figure 7........................................................................................................... 32 ABBREVIATIONS............................................................................................... 33 ENDNOTES....................................................................................................... 34

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1. Introduction At the G8 Kyushu-Okinawa Summit in July 2000 member states of the industrialized countries focused on the impact of information technologies and the growing challenges and risks of a global "digital divide". The summit recognized that Information and Communications Technologies (ICT) can serve as effective tools for broad-based international development in regions where development’s traditional toolkit has fallen short. The United Nations (UN) has paid particular attention to the role of ICT in advancing the Millennium Development Goals (MDGs) through its UN ICT Task Force and the World Summit on Information Society. In recent years, the international community has rallied around a campaign known as Information and Communication Technologies for Development (ICT4D), which aims to apply information technology solutions toward poverty reduction goals. ICTs can be applied directly wherein their use benefits a disadvantaged population, or indirectly where ICTs assist aid organizations, non-governmental organizations (NGO), governments or businesses in order to improve existing socio-economic conditions. For the purposes of this report, ICTs are defined as tools that facilitate communication and the processing and transmission of information and the sharing of knowledge by electronic means. This encompasses the full range of electronic digital and analog ICTs, from radio and television to telephones (fixed and mobile), computers, and electronic-based media such as digital text, audio-video recording, and the Internet, including 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 Communication Technologies and Development (UNGAID), a United Nations (UN) 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

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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 cases 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 benefits 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 countries chosen from various regional groupings. The countries detailed through the paper are: Albania, Estonia, 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.

2. Intersection of health and ICTs

In developing countries, lack of access to health care and inefficient delivery methods are the norm. This shortage is exacerbated by the inability of governments to devote adequate funding to their respective health care sectors. This is intensified by the multiple crises in finance, food and energy. Unsuccessful reform efforts, combined with little funding, have left billions without the ability to tap into basic health care services. Most health ministries in developing countries are aware of the inequities between urban and rural communities; however, efforts to decrease this divide have fallen short. Cost effective reform initiatives are needed to ensure greater access and higher quality of basic health care through the use of ICTs. A number of initiatives, detailed later in the paper, demonstrate where ICT proved critical in improving access and health services to disenfranchised populations. Most solutions center on mobile solutions as personal, ubiquitous, connected and increasingly intelligent mobile phones have become indispensable in much of the developing world: 64% of mobile users are in emerging markets and it is estimated that by 2012, 50% of individuals in remote areas of the world will have mobile phones.3

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According to the World Health Organization (WHO), technology has always been at the backbone of improving medical services to prevent, diagnose, and treat illness and disease.4 This report shows that given the right policies, resources, and institutions, ICTs can be powerful tools in the hands of those working to improve health.5

3. ICTs and the MDGs In order for global poverty to decrease, definitive steps must be taken to improve health, especially among marginalized populations. It is with this philosophy that three of the eight MDGs were designed to improve global health. In this white paper, the focus is placed on the following three MDGs:

• Reduce child mortality (MDG 4) • Improve maternal health (MDG 5) • Combat HIV and AIDS, malaria and other diseases (MDG 6)

The three health-related MDGs are best achieved through a coordinated approach of public, private and civil institutions. There is a need for ICT programs to work in synergy with any other policy initiatives or strategies, such as national poverty reduction strategies or as part of national health policies.6 A World Bank study concluded that there is growing evidence that ICTs have the capability to provide new and more efficient methods of production; improve delivery of information; bring previously unattainable markets within reach of the poor; and facilitate the transfer of knowledge.7 With specific regard to MDGs four, five and six, ICTs have the capability to increase remote access and support of specialists to caregivers in rural locales. They also enhance basic training for healthcare workers, increasing their ability to monitor and access information, such as statistics on disease and famine.8 3.1 eHealth and mHealth: Challenges and Opportunities In recent years, mHealth and telemedicine have emerged as important initiatives in the field of eHealth. While there is no widely agreed-to definition for these fields, the public health community has gathered around these working definitions (see Figure 3 for greater detail):

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• eHealth: Using information and communication technology (ICT)—such as computers, mobile phones, and satellite communications—for health services and information.

• mHealth: Using mobile communications—such as PDAs and mobile phones—for 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 today’s mobile technology, (specifically, bandwidth and transmission speed), the distinguishing element of telemedicine – clinical presence (imagery, video or other real time diagnostic information) – is best delivered through fixed 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 traffic 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 developing 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 sustainability must be emphasized here, since relationships based on profit 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 profitable and increase market share, making it difficult 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.

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4. Role of Governments for Improved Health Governments 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 undertaken by governments requiring political capital, financial 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 successful initiatives undertaken by selected country governments as well as indicating where more human and financial capital is necessary. 4.1 National Health Plans In terms of positive examples, Uganda's 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. Uganda’s national vision is to promote development and effective utilization of ICT such that quantifiable 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 Strategic Plan, which identifies 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 applications have 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

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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 reflects 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 enhance 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 reduce maternal mortality, HIV prevention programs, and to make healthcare accessible to the poor.12 Peru’s 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 significantly in other sectors, this is unfortunately 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 defined national ICT plan aimed at the health sector, even though ICT solutions have seen increased numbers in the health sector. Thus, ongoing ICT projects in health are not consolidated and 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 insufficiently used.14 While South Africa’s 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 insufficient and in some cases reversed. Lack of coordinated government action has seen the emergence of 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 that the South African health model could be aided by further ICT implementations like disease monitoring solutions, and mobile health education campaigns against HIV/AIDS. 4.2 Innovative Health Plan Initiatives

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In Tanzania, the health SWAp (Sector Wide Approach), a government-sponsored initiative, introduced in 1999, which improves 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, improved predictability and allocation of financing, 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 the prime minister’s office.17 India’s National Rural Health Mission (NHRM) also represents a break from the status quo in financing health care in rural geographies. A notable element of the program is the government’s commitment to increase public health spending from 0.9% to 2-3% of Gross Domestic Product (GDP) over the next five years, and introduce mechanisms to ensure funding reached 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 hospitalization 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 overall benefits 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 figures in this section are from 2006, unless otherwise noted. Figure 4 displays how health expenditures are prioritized in the selected countries. 5.1 Health Expenditure analysis

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The sum of general and private expenditure towards health care makes up a country’s total expenditure on health. Government expenditure should outweigh the private percentage, so that a country’s 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 proportion of countries also using private funding or public-private partnerships to support activities.19 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 financing. The Estonian eHealth Foundation is primarily financed from the state budget. Estonia participates in several cross-European projects co-financed 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 financed through private channels. External resources for health are defined as the sum of resources channeled towards health by entities outside a nation’s borders, including donations and loans, and both cash and in-kind resources. This figure is expressed as a percentage of total expenditure on health. The percentage provides a good indication of 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 financing 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, flooding in from outside the continent.

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Per capita government expenditure on health indicates the dollar amount of health expenditure a government spends per citizen. This is not to say the every citizen receives the same proportion of health care benefits. More often than not, the amount spent by the government far exceeds the dollar value of benefits received by the recipient. The figure is however, a gauge for the robustness of particular health systems’ finances. 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 amounted 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 India’s 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 typically contain a dose of public private partnerships to finance 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. Peru’s 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; Asociación Via Libre and Asociación Civil Impacta Salud y Educación. 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

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The CA:SH project in India was made possible because of a partnership between a multitude of stakeholders; including Media Lab Asia (part of India's 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 financial 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 Jordan’s Knowledge Stations project and the general development of Jordan’s ICT sector.23 These particular funders have been instrumental in making sure Jordan’s ICT sector continues using the most up-to-date health software, so that its system stays cutting edge. The Knowledge Stations and Jordan’s ICT sector are also funded by external donors such as the People’s 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 firms, 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 significant in-kind donations by 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 sufficient funding to do so, currently the project is financially 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, affordability of mobile services continues to escape those who can most use access to mobile technology. As a result of price competition, the price of a cellular handset and arguably calls, have reduced dramatically over the last decade. The International

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Telecommunications Union (ITU) reports that by the end of 2008, there were more than 4 billion mobile active mobile subscriptions.26 Figure 5 provides an overview of the numbers used below. For the countries selected in this work, affordability of 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 countries 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 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. Indian’s on average spent 2.1% of their monthly GNI on mobile services compared to Vietnam’s 6.4%. Comparable inequalities existed for Eastern Europe between Estonia and TFYR Macedonia. The region had the highest mobile basket cost of US$ 13.6 and US$ 13.2, respectively. Estonian’s however, spent only 1.2% of their monthly GNI toward mobile services as opposed to Macedonian’s 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 Uganda are 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 Ugandan’s who need them most. Given the data presented above, this assertion can arguably be made for Malawi and Tanzania as well.

i Price reflects 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 fixed line), in predetermined ratios, plus 30 Short Message Service (SMS) messages. ii The ITU considers less than 1% of GNI spent on mobile services as acceptable.

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Other forms of eHealth devices are also challenged by high costs and lack of financing is one of the biggest threats towards the Baobab Project in Malawi, where the initial touch screens were cheap leftovers transformed to the health service setting. These devices are currently not being produced anymore, and costs have therefore increased significantly, making it difficult 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 hardware and monthly subscription costs. For instance a system of cross subsidization using sales in the developed 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 countries. Public funding is by far the most common source of finance. 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 nation’s health care system. Provision of evidence-based eHealth project success stories and best practices would inform and assist ministries with their bids for funding.

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6. Role of Civil Society Civil society can be defined as the link between the market and the state, and is also known as NGOs, non-profit organizations or the “social economy”. It can include a variety of entities such as health clinics, family 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 independence from the governmental apparatus, and their overarching objective which is to serve a public or community purpose, not simply to generate financial profits. 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 country’s 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 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 significant 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 sufficient 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 India’s disadvantaged groups.

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On the same note, Peruvian civil society groups and NGOs have pushed for health, trying to improve the existing 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 population; 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 average Peruvian women, which is a consequence of absence of health facilities and health services targeting women’s 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 doesn’t necessarily cover all marginalized populations. In Qatar for example, the role of NGOs is very limited, especially with regards to implementing ICTs for health. 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 assist 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 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 exchange of views before implementing the project. In South Africa, Project M was established in partnership of multiple stakeholders, including civil society organizations. Targeted text messages were developed by a local educational NGO, and another partner was a national HIV/AIDS, non-profit helpline, providing anonymous, HIV counseling and referral that text receivers were directed

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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 transmission 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, is the e-Health system, providing training for health workers in Qatar, 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 of civil 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 infrastructure that supports these different initiatives. This infrastructure can consist of physical technology- such as fiber 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,

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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 world's lowest and most expensive telephone and Internet user penetration and quality of service.39 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 by an insufficient amount of qualified 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. Vietnam’s 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 Qatar's sole public telecom company, introduced such mobile technological innovations 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 It also 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 potential 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

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ICT is inadequate and costly to implement if people are not familiar with it. The adjustment to new technology 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 specified technical knowledge or skill-sets due to political or economic instability, can significantly 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 institutions 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 ICT initiatives 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 knowledge among populations through faster dissemination of information about important health topics. 8.1 Easy Use of PDAs In Peru, the Colecta-PALM project demonstrated that using PDA’s was useful in developing countries where individuals 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 specific 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 five-month pilot, “indicated high acceptance of the technology and reduction in total time for entry of data…the [health workers] were satisfied with the user interface and were able to

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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 disseminated 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 communicated to larger health actors in hopes that they could do more to begin dispelling these public myths. Project M in South Africa is the world’s largest field 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 send 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 – they have previously been difficult 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 filling 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 Boabab pilot study in the pediatric Hospital in Malawi, showed that computer-based entry can be successfully deployed and used in resource poor settings, it can be sustained at relatively low costs and with local resources, and has a greater potential to improve patient care in developing countries. The introduction of the system has eliminated errors in medication dosage by improving documentation.

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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 coding system and online terminology database that links all regions of the country together. The e-Health system has also produced a certified 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 ICT should push to require all government health care workers 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 financing is sustainable. The studies have concluded that the Knowledge Stations have succeeded in targeting key marginalized populations and improving their knowledge of computer literacy by training 102,324 people, 56% of them being women. Knowledge Centers have allowed disenfranchised 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 financial sustainability of projects, language barriers during and after implementation as well as the increased role civil society can play, among others. 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.

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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 allocations in 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 find themselves powerless and ineffective as far as facilitating real change. The Baobab system in Malawi has a financial drawback as well, the original touch screen hardware is no longer produced and current touch screens are US$ 700 per device, which prove extremely expensive, and could become a roadblock for the financial sustainability of the Baobab system. 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 relatively expensive. 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

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The Baobab system in Malawi is based in English and requires the healthcare worker to have English reading and writing skills. Not tailoring software to be flexible to local languages has affected take-up of technologies as not all healthcare workers have the requisite language skills. In South Africa on the other hand, Project M’s text messages are written in local languages and therefore reach more people. South Africa has eleven officially recognized languages, and in order to reach as many people 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 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 Tanzania's 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 rare given 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 counselors, 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

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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 fixed line connection takes several days in Uganda and although the timeline for 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 efficiency while maintaining flexibility and allowing the physician, not the tool, to determine the best course of action. In Albania, resource constraints, such as the lack of equipment to connect remote health clinics to urban hospitals with greater capacity, remains unsolved. The unavailability of trained specialists cannot be ignored when focusing on healthcare reforms. Government action plans aimed at strengthening resource shortages will be in vain if the necessary funds are not made quickly available. Similarly, augmenting the sector's human capacity to meet the demands of healthcare services requires careful planning and allocation of resources for training and professional development programs. 9.5 Reluctance of Governments and Private Companies

There seems to be reluctance on the part of both government officials and private telecom providers to embrace mobile health solutions in Uganda. It takes a great deal of effort for NGOs like TTC to convince key stakeholders that there is tremendous value in operations like TTC. However, with the recent light being shed on mHealth applications throughout the world, stakeholders cannot simply dismiss mHealth as a tool for furthering development objectives.52 9.6 Medical miss-diagnoses Using ICT In Tanzania, there are cases when a patient is on the border of a threshold between two different classifications, i.e. a severe cough and pneumonia. A clinician familiar with the IMCI protocols measured the number of breaths per minute as instructed by the PDA. The result, 36, was just below the threshold for pneumonia, 40 breaths per minute. Since this case is on the border, e-IMCI effectively hides the pneumonia protocol, perhaps leading to an inaccurate diagnosis. The clinician was aware of this and instead put down the PDA and made a clinical decision without the

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assistance of the device. Therefore, e-IMCI software will need to be more sensitive to evaluate threshold cases for effective diagnoses. 9.7 Role of Civil Society and Public-Private Partnerships Estonia’s healthcare sector is well organized as a result of collaborative partnerships between all stakeholders in society. There are informative campaigns focused on raising awareness of benefits and difficulties of ICT implementations in healthcare. Estonia’s eHealth Foundation provides the right framework for future advancement in the country’s healthcare sector. It sets an example of how action plans are implemented through exchange of information, coordination, and participation. What was learned from the Albania case, on the other hand, was that if there are no widely agreed to standards, and lack of information regarding the available services and equipment, there will be little participation and few positive results in healthcare improvements. Monitoring and evaluation plans must be adapted in order to understand the effectiveness of each action plan undertaken by the government in cooperation with its multi-level partnerships. 10. Recommendations Drawing from the lessons learned segment, the following section makes sector wide policy recommendations that are applicable to a broad range of stakeholders, namely, governing bodies, international organizations, civil society and the private sector. A reoccurring theme throughout different successful ICT case studies has been the cooperation between privately owned technology companies, public or private health facilities, non-governmental development organizations, private development contractors, academia and the government. Obviously, all of these actors 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 involved with it, in order to facilitate maximum services rendered to the largest group of beneficiaries.

10.1 For Governing bodies

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• National Governments should recognize the significant impact ICT can have on the health sector and make reasonable allocations for the sector. A clearly defined 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 partnership more appealing. Governments should liberalize their ICT markets to allow competition and thus reduce 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 sufficient funds to make ICT their top priority and are thus depended on external 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.

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 qualifications 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

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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 programming, most of which will cost little and will allow them to reap substantial rewards in terms of corporate social responsibility or philanthropic standing.

• Telecommunication companies must realize there lies an immense untapped market of new customers when they partner with agencies that implement mobile based ICT applications.

10.5 For All Stakeholders

• Locals, for example through civil society, should be included in eHealth projects in order to ensure that ICT initiatives are context specific and to develop a more and better targeted health improvement approach.

• Projects should build on local capacity so that they can easily be handed over to local staff and thus be sustainable.

• Technology should be cheap to buy, cheap to ship to location, and easy to maintain and customize.

• Flexibility, creativity and innovation all enable innovation in this space but implementers should try and keep models as simple as possible.

• Embrace a user-centric “innovation process” that allows field centric activities and frequent feedback to ensure products address actual needs with sustainable solutions.

• Programs must be designed with scalability and sustainability. Implementers should view projects as long term investments and not handouts.

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Figure 1: Featured ICT Initiatives

Albania - eHealth Policy and Legislature: Between 2001 and 2004 national mechanisms such as an information policy, an eStrategy, and an eHealth policy were adopted to Albania’s 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 Albania’s healthcare workforce in ICT.53 Estonia - eHealth Projects: In October 2005, Estonia’s Ministry of Social Affairs, with support by the European Union (EU) Structural Funds and in collaboration with a team of national partners, initiated the eHealth Foundation. The core objective of this project incorporate: development of a structured framework for eHealth architecture; management of electronic health records and setting the stage for digital prescriptions, digital registrations, and digital images. eHealth in Estonia was created by employing existing IT infrastructure while also conducting research for system and service improvements.54 India - Community Accessible and Sustainable Health System (CA:SH): The CA:SH program started in 2002 and was designed to address the problems of poor data flow 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 qualifications for a basic Medical Information 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

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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, Baobab 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 the Ministry 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 efficiently 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. This program used was an open sourced and secured web-based application in Spanish that gave surveys to 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 to the participant to encourage responsible behavior so as not to spread the disease.59 Qatar - ictQATAR: The Qatar government has proposed modern and sophisticated financing for health plans that are geared toward the advancement of information and communication technologies. The “e-Health Strategy” is a health plan with an emphasis on ICT’s 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 patient’s blood sugar levels.60 South Africa - Project Masiluleke (Project M): Project M operates by using mobile technology to bring people with HIV and tuberculosis into the healthcare system earlier and thereby increase chances of living longer and healthier lives. The project was started in 2008, and uses specially developed open source software to send millions of targeted health

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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 fiscal healthcare barriers. It is a program 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, which takes 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 awareness 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 critical 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 Remote RICE system is a cellular phone-based electronic medical record designed to facilitate remote medical 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 identified as a potential high-risk area for SARS and Avian influenza transmission.66

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Figure 2: Progress on the MDGs

MDG 4 MDG 5 MDG 6

Infant mortality rate (0-1 year) per

1,000 live births.

Children under five mortality rate per 1,000

live births.

Proportion of 1 year old

children immunized

against measles

(%).

Maternal mortality ratio per

100,000 live births

Births attended by skilled

health personnel

(%).

People living with HIV, 15-24 years (%).

Tuberculosis death rate

per year per 100,000

population

Children under 5 sleeping

under insecticide-treated bed

nets (%). 1990 37 1990 46 1990 88 N/A 2000 99 N/A 1990 4 N/AAlbania 2007 13 2007 15 2007 97 2005 92 2005 99 N/A 2007 3 N/A1990 14 1990 18 1993 74 N/A 1992 99 2001 0.5 1990 4 N/AEstonia 2007 4 2007 6 2007 96 2005 25 2006 100 2007 1.3 2007 6 N/A1990 83 1990 117 1990 56 N/A 1993 34 2001 0.5 1990 42 N/AIndia 2007 54 2007 72 2007 67 2005 450 2006 47 2007 0.3 2007 28 N/A1990 33 1990 40 1990 87 N/A 1990 87 N/A 1990 1 N/AJordan 2007 21 2007 24 2007 95 2005 62 2007 99 N/A 2007 1 N/A1990 33 1990 38 1993 98 N/A 1990 89 N/A 1990 11 N/AMacedonia 2007 15 2007 17 2007 96 2005 10 2006 99 N/A 2007 5 N/A1990 124 1990 209 1990 81 N/A 1992 55 2001 13 1990 62 2000 3Malawi 2007 71 2007 111 2007 83 2005 1100 2006 54 2007 12 2007 102 2006 231990 58 1990 78 1990 64 N/A 1992 53 2001 0.4 1990 34 N/APeru 2007 17 2007 20 2007 99 2005 240 2006 71 2007 0.5 2007 16 N/A1990 20 1990 26 1990 79 N/A 1996 98 N/A 1990 6 N/AQatar 2007 12 2007 15 2007 92 2005 12 N/A N/A 2007 7 N/A1990 49 1990 64 1990 79 N/A 1995 82 2001 17 1990 78 N/ASouth

Africa 2007 46 2007 59 2007 83 2005 400 2003 92 2007 18 2007 230 N/A1990 96 1990 157 1990 80 N/A 1992 44 2001 7 1990 43 1999 2Tanzania 2007 73 2007 116 2007 90 2005 950 2005 44 2007 6 2007 78 2007 571990 30 1990 34 1990 70 N/A 1997 99 2001 1.4 1990 2 N/ATrinidad &

Tobago 2007 31 2007 35 2007 91 2005 45 2006 98 2007 1.5 2007 2 N/A1990 40 1990 56 1990 88 N/A 1997 77 2001 0.3 1990 33 2000 16Viet Nam 2007 13 2007 15 2007 83 2005 150 2006 88 2007 0.5 2007 24 2006 51990 106 1990 175 1990 52 N/A 1995 38 2001 8 1990 69 2001 0.2Uganda 2007 82 2007 130 2007 68 2005 550 2006 42 2007 5 2007 93 2006 10

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Source: Millennium Development Goals Indicators: The Official United Nations Site for the MDG Indicators, retrieved from: http://millenniumindicators.un.org/unsd/mdg/Default.aspx, November 200

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Figure 3: Positioning eHealth, mHealth and telemedicine

mHealth

Telemedicine

Definition The delivery of health-related services via mobile communications technology

Health-related services delivered remotely with clinical participation

Distinctions Mhealth implies the use of solutions and services designed to be accessed and delivered via cellular or wireless broadband networks

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

Examples • Mobile access to health records Patient monitoring • Pubic health alerts, monitoring • Nutrition 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 consultation • Remote support for

local health care provider

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

Low Complexity of eHealth applications High

Education/ Awareness

Monitoring /

Compliance

Data Access

Disease / Emergency

Tracking

Health Information

Systems

Diagnosis /

Consultation

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Figure 4: Country health expenditures

Total expenditure

on health as %

of gross domestic product

General government expenditure

on health as % of total expenditure

on health

Private expenditure

on health as %

of total expenditure

on health

External resources

for health as %

of total expenditure

on health

Out-of-pocketexpenditure as

% of private

expenditure on health

Per capita government expenditure

on health (PPP int. $)

Per capita government expenditure

on health at average exchange rate (US$)

2000 2006 2000 2006 2000 2006 2000 2006 2000 2006 2000 2006 2000 2006 Albania 6.4 6.5 36.3 37.3 63.7 62.7 6 3.5 99.9 94.9 87 142 27 70Estonia 5.3 5.2 77.5 73.3 22.5 26.7 0.9 0.6 88.5 93.3 404.0 702.0 169.0 464.0India 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 7.0Jordan 9.4 9.7 46.5 43.3 53.5 56.7 4.6 4.7 74.7 75.9 141.0 188.0 77.0 103.0Macedonia 7.6 8.0 70.9 70.6 29.1 29.4 3.2 1.1 100.0 100.0 334.0 444.0 96.0 176.0Malawi 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 14.0Peru 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 87.0Qatar 2.3 4.3 68.8 78.2 31.2 21.8 0.0 0.0 84.5 88.2 866.0 … 454.0 2157.0South Africa 8.1 8.0 42.4 37.7 57.6 62.3 0.3 0.9 18.9 17.5 220.0 270.0 100.0 160.0Tanzania 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 13.0Trinidad and Tobago 3.9 4.4 42.8 56.5 57.2 43.5 4.7 2.4 86.3 88.0 … … 104.0 339.0Uganda 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 6.0Vietnam 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 15.0 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 3245.0United States 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 3076.0 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 11.0Africa 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 48.3Mid-East 5.9 5.9 57.7 57.7 42.4 42.4 2.3 2.3 79.6 79.6 503.5 503.5 265.5 265.5East Europe 6.5 6.6 74.2 72.0 25.8 28.1 2.1 0.9 94.3 96.7 369.0 573.0 132.5 320.0Americas 4.3 4.4 47.9 57.4 52.1 42.6 3.4 2.0 82.9 82.8 123.0 184.0 78.0 213.0Developed Regions 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 3160.5Source: World Health Organization, World Health Statistics 2009, retrieved from: http://apps.who.int/whosis/data/Search.jsp?countries=[Location].Members, October 2009.

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Figure 5: ICT basket prices

ICT Price Basket Value

2008 out of 150 countries

Mobile Sub-basket ranking 2008 out of 150

countries Mobile sub-basket as a %

of monthly GNI Mobile sub-basket (US$) Albania 7.1 115 8.3 22.7Estonia 2 42 1.2 13.6India 4.7 64 2.1 1.6Jordan 6.1 60 1.9 4.5Macedonia 4.2 99 4.6 13.2Malawi 57.8 148 57.4 12Peru 6.9 79 2.8 8Qatar N/A N/A N/A N/ASouth Africa 4.2 73 2.6 12.3Tanzania 55.4 141 33.3 11.1Trinidad and Tobago 1.1 23 0.7 7.9Uganda 60.4 142 36.8 10.4Vietnam 11.9 110 6.4 4.2Source: 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 2007Albania 93 85Estonia 31 26India 117 118Jordan 65 76Macedonia 53 65Malawi 141 141Peru 71 74Qatar 47 44South Africa 77 87Tanzania 138 145Trinidad and Tobago 58 56Uganda 143 140Vietnam 107 92Source: 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 2007Albania 78 96 130 78 92 78Estonia 37 24 20 27 18 21India 124 129 57 44 118 118Jordan 66 78 70 75 50 60Macedonia 72 55 46 50 64 63Malawi 145 138 143 144 132 136Peru 94 85 59 61 51 56Qatar 41 39 57 44 84 79South Africa 77 84 67 92 80 80Tanzania 121 140 144 143 139 142Trinidad and Tobago 50 47 55 67 87 92Uganda 150 142 132 126 134 133Vietnam 118 90 105 74 95 102Source: International Telecommunication Union, Measuring the Information Society - the ICT Development Index, 2009

39


List of Acronyms

AIDS Acquired Immune Deficiency 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 Immunodeficiency Virus IBM International Business Machines Corporation ICT Information, Communication, Technology ICT4D Information, Communication, Technology 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 TETRA Terrestrial Trunked Radio TFYR Macedonia The former Yugoslav Republic of Macedonia TTC Text to Change UN United Nations

http://en.wikipedia.org/wiki/HIV

40


UNGAID Global Alliance for ICT and Development VHL Virtual Health Library WHO World Health Organization

41


End Notes

1 McNamara, K. 2007. Improving Health, Connecting People: The Role of ICTs in the Health Sector of Developing 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.developmentgateway.org/ict/sdm/previewDocument.do~activeDocumentId=840982

6 Ministry of Foreign Affairs Denmark. 2005. Good ICT Practice – Lessons Learned in Health

Sector. Copenhagen. Posted at: http://goodictpractices.dccd.cursum.net/client/CursumClientViewer.aspx?CAID=214113&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=64187937&theSitePK=523679&menuPK=64187510&searchMenuPK=64187283&siteName=WDS&entityID=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

42


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: Challenges and Priorities. The Lancet, 374(9694):1023-1031. 16 OECD, World Health Organization and The World Bank. 2008. Effective aid, better

health. Geneva, World Health Organization. 17 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

18 Rashtriya Swasthya BimaYojna. 2009. Health Insurance for the Poor. Ministry of Labor

and Employment, Government of India. Posted at: http://www.rsby.in/about_rsby.html

19 World Health Organization. 2006. Building Foundations for eHealth: Progress of Member

States. Geneva, World Health Organization. 20 Via Libre. 2009. Peru. Posted at: http://www.vialibre.org.pe 21 Impacta. 2009. Socios y Colaboradores. Posted at:

http://www.impactaperu.org/Portal/content.aspx?pid=14 22 Dimagi Inc. 2009. Ca:sH. Massachusetts. Posted at: http://www.dimagi.com/content/cash.html 23 Ministry of ICT, Jordan. 2008. Knowledge Stations: A Sustainable Approach. Jordan.

Posted at: http://www.ks.jo/KS_sustain_EN.htm 24 Ibid. 25 Project Masiluleke. 2009. Project Masiluleke Internal Evaluation Report. South Africa,

Project Mailuleke. 26 International Telecommunications Union. 2009. Measuring the Information Society. Geneva, ITU. 27 Salamon, L, Wojciech Sokolowski, S. & List, R. 2003. Global Civil Society – an Overview.

The International Journal of Not-for-Profit Law, 6(1).

43


28 Chopra, Mickey, et al. 2009. Achieving the Health Millennium Development Goals for South Africa: Challenges and Priorities. The Lancet, 374(9694): 1023-1031.

29 PriceWaterhouse Coopers. 2007. Healthcare in India- Emerging Market Report, 2007.

McLean, VA, PriceWaterhouse Coopers. 30 Ians. 2009. Civil Society Organizations Issue Health Manifesto. Thaindian News, 23

March. Posted at: http://www.thaindian.com/newsportal/politics/civil-society-organisations-issue-health-manifesto_100170271.html

31 Rosen, JE. 2005. Peru: Civil Society Key to Youth Policy Implementation. USAID Policy

Brief. Washington, DC, USAID. Posted at: http://www.policyproject.com/abstract.cfm/2476

32 Amnesty International. 2009. Hundreds of Peru’s Poor, Rural and Indigenous Pregnant

Women Die in Health Service Lottery. Amnesty International. New York, NY. Posted at: http://www.amnesty.org/en/news-and-updates/report/hundreds-peru-poor-rural-indigenous-pregnant-women-die-health-service-lottery-20090709

33 World Health Organization. 2009. Qatar Coverage with Primary Health care Service

Indicators, 2009. Geneva. Posted at: http://www.emro.who.int/emrinfo/index.asp?Ctry=qat

34Fast Forward TT. 2009. ICT Agenda. Trinidad & Tobago. Posted at:

http://www.fastforward.tt/ICT_agenda/default.aspx 35 LifeLine. 2007. Our Story. South Africa. Posted at:

http://www.aidshelpline.org.za/default.aspx?link=our_story 36 Project Masiluleke. 2009. Project Masiluleke Internal Evaluation Report. South Africa,

Project Mailuleke. 37 Kapadia, F. 2009. Interview with Eric Cantor, Grameen Foundation – App Lab. mHealth

in Uganda. 16 October 2009. E-mail communication. 38 Smith, A. 2008. High-Speed Internet Coming to Africa. Time Magazine, 15 September.

Posted at: http://www.time.com/time/business/article/0,8599,1841175,00.html 39 Wilfred, E. 2008. Tanzania: World Bank’s $100 million to Lower ICT Cost. allafrica.com, 6

June. Posted at: http://allafrica.com/stories/200907061437.html 40 Chigalu, S. 2006. ICT for Sustainable Rural Development Telecenter Project. ICT Malawi,

Malawi. Posted at: http:// www.ictmalawi.org 41 Connect World. 2008. Vietnam Telecomp 2008. World Info Comms Ltd. United

Kingdom. Posted at: http://www.connect-world.com/articles/e-promo.php?e_promos_id=45

44


42 Pop!Tech. 2009. Project Masiluleke. Pop!Tech. New York. Posted at: http://poptech.org/project_m/ 43 International Telecommunications Union. 2007. 3G International Video Calling

launched in Qatar by Q-tel. Geneva, ITU. Posted at: http://www.itu.int/osg/spu/newslog/PermaLink,guid,d30768c0-7b10-4388-836d-9d4e6e0f5c5f.aspx

44 Tetra-Products and Services. 2009. Qtel. Qatar. Posted at: http://www.qtel.com.qa/Tetra.do?prodtype=2 45 Vital Wave Consulting. 2009. mHealth for Development: The Opportunity of Mobile


46 Ibid. 47 Anantraman, V, et al. 2000. Handheld computers for rural healthcare: Experiences from research concept to global operations. Dimagi, Boston. Posted at: http://kaash.sourceforge.net/doc/dyd02.pdf 48 Brandt Soerensen, J. 2009. Interview with Leetha Filderman, Director, Pop!Tech

Accelerator. 10 November 2009. E-mail communication. 49 Brandt Soerensen, J. 2009. Interview with Sabine Joukes, Director, Baobab. 20 October

2009. E-mail and telephone communication. 50 Ibid. 51 Reuters. 2009. Research and Markets: An Overview of the South African Healthcare

Industry. Reuters. New York, NY. Posted at: http://www.reuters.com/article/pressRelease/idUS175920+29-May-2009+BW20090529

52 Kapadia, F. 2009. Interview with Eric Cantor, Grameen Foundation – App Lab. mHealth

in Uganda. 16 October 2009. E-mail communication. 53 World Health Organization. 2006. Building Foundations for eHealth. Geneva. Posted at:

http://www.who.int/goe/data/country_report/alb.pdf 54 Tiik, M. 2008. Estonian Residents Are in Favor of Implementing the Electronic Health

Record. Estonia. Posted at: http://eng.e-tervis.ee/news/est-residents-in-favor-of-implementing-the-ehr.html

55 Dimagi Inc. 2009. Ca:sH. Massachusetts. Posted at: http://www.dimagi.com/content/cash.html

45


56 Ministry of ICT, Jordan. 2008. Knowledge Stations: A Sustainable Approach. Jordan. Posted at: http://www.ks.jo/KS_sustain_EN.htm

57 Chorbev, I, Madzarov, G and Mihajlov D. 2009. Wireless Telemedicine as Part of

Integrated Systems for E-Medicine. Posted at: http://www.ieee.org/portal/cms_docs/iportals/education/standards/Chorbev_Wireless_Telemedicine.pdf

58 Baobab Health. 2009. About Us - Baobab Health. Malawi. Posted at:

http://baobabhealth.org/?page_id=2. 59 Vital Wave Consulting. 2009. mHealth for Development: The Opportunity of Mobile


60 ictQatar. 2009. National Programs – eHealth. Qatar. Posted at:

http://www.ict.gov.qa/output/page6.asp 61 Frog Design. 2008. Pop!Tech Unveils Project Masiluleke. Amsterdam. Posted at:

http://www.frogdesign.com/press-release/poptech-unveils-project-masiluleke.html

62 World Health Organization. 2009. Integrated Management of Childhood Illness (IMCI).

Geneva. Posted at: http://www.who.int/child_adolescent_health/topics/prevention_care/child/imci/en/index.html

63 DeRenzi, Brian, et al. 2008. e-IMCI: Improving Pediatric Health Care in Low Income

Countries. Florence, Italy. Posted at: www.cs.washington.edu/homes/bderenzi/Papers/chi1104-bderenzi.pdf

64 Virtual Health Library. 2009. VHL – Information Sources. Trinidad & Tobago. Posted at:

http://www.vhl.org.tt/html/en/home.html 65 Vital Wave Consulting. 2009. mHealth for Development: The Opportunity of Mobile


66 Ibid.

Documents

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