Strategy (40)

Last week I returned from an Asian eHealth conference in Myanmar. The trip was extraordinary for a number of reasons: exploring places, people and cultures quite different to the African environment I call home, learning about our Asian colleagues' approach to eHealth leadership, and learning first-hand how ubiquitous the open source DHIS2 platform has become.

As our African countries health systems move towards eHealth goals, looking at other global regions provides valuable insights.

Set up in 2011, the Asian eHealth Information Network (AeHIN) provides an overview of eHealth in that part of the world. When it started, it identified a shared problem of, at best, minimal Interoperability (IOp) “Even within Ministries of Health.”

AeHIN has a clear trajectory for its 25 country members. The Asia eHealth Information Network: Strategic Roadmap 2016-2020 sets out a wide array of initiatives to support national eHealth development in Asia. There are four strategic goals:

  1. Build eHealth capacity for Health Information Systems (HIS) and Civil Registration and Vital Statistics (CRVS)
  2. Effective networking to increase peer assistance and knowledge exchange and sharing
  3. Promote IOp in and between countries
  4. Enhance leadership, sustainable governance and M&E.

eHealth governance framework for enterprise ICT is based on COBIT5, from the Information Systems Audit and Control Association (ISACA). It’s an internationally recognised framework for ICT governance. Its three overarching themes are evaluate, direct and monitor. There are four main parts in AeHIN’s model:

  1. Align, plan and organise
  2. Build, acquire and implement
  3. Deliver, service and support
  4. M&E and assess.

AeHIN has eHealth blueprints for enterprise architecture. Its four components are business, data, application and technology. It also has a Regional Enterprise Architecture Council for Health (REACH). Its eHealth capacity framework has seven modules:

  1. eHealth service agreements
  2. Management, plans, policies and procedures
  3. IOp profiles and terminology services
  4. Health Information Exchange (HIE)
  5. National Standards and IOp framework
  6. eHealth governance framework
  7. National eHealth action plans.

Supporting these initiatives are special interest groups. They include:

  1. Geographic Information Systems (GIS) lab
  2. Routine HISs
  3. District Health information Systems (DHIS) 2, implemented in twelve countries
  4. Research, with ten PhDs to work on AeHIN topics
  5. Community of IOp labs.

The African Centre for eHealth Excellence (Acfee) has much in common with AeHIN and its aspirations. A working relationship has been initiated between Acfee and AeHIN to begin sharing African and Asia lessons for mutual benefit.

This structured approach offers a template for Africa’s eHealth. Modest, steady, sustained investment can start to achieve it.

Happy New Year to everyone. Congratulations on your 2016 eHealth efforts. It's been quite a year, setting us up for an extraordinary African 2017.

Thank you for reading our stories of Africa’s eHealth development. They reflect a small part of our passion to explore and support eHealth’s role in securing better health for Africans. They showcase some of the exceptional work already underway through you and our international eHealth colleagues.

At the September African eHealth Forum (AeF), our Advisory Board set out African eHealth priorities. Details are in the AeF Report, Advancing eHealth 2016, and summarised in posts on eHNA.

Acfee’s response will be delivered in the New Year. It will focus on bringing our five priorities to life in tangible ways that can help lead to healthier Africans.

1. eHealth strategy

Acfee’s research and support for African countries’ national eHealth strategies will expand. This includes a special focus on issues highlighted by the Acfee Advisory Board, including:

  • Cloud computing: learn from global experiences of the challenges and opportunities and synthesise these for health ministries to review
  • eHealth surveillance: explore the contribution of Acfee’s eHealth impact and benefits realisation research and expertise for HISP’s planned eHealth surveillance initiative in West Africa
  • Architecture: finalise the commentary on eHealth architecture to fit expanding mHealth and social media for health ministries to review
  • Interoperability (IOp): seek finance to establish Acfee technical working groups for IOp and support an IOp workshop on a use case and a development programme in an African country in collaboration with Integrating the Healthcare Enterprise (IHE) to set the process of use case development in Africa

2. eHealth governance

Acfee’s review of start-up measures for health ministries will be published in an eBook, leading on to sophisticated arrangements as reported on eHNA.

3. eHealth regulation

Acfee will continue to develop affordable, sustainable approaches to eHealth regulation for health ministries to review.

4. eHealth cyber-security

Acfee’s on-going review of global threats, initiatives and actions will be synthesised in an expanding eBook for health ministries to use to combat cyber-threats, as reported on eHNA.

5. eHealth impact

Acfee will continue to develop sophisticated impact models appropriate to Africa’s needs, to help health ministries to select good initiatives, monitor and evaluate them and promote positive socioeconomic impact.

The 2017 programme will include Acfee’s internal development, such as the internship programme to develop emerging professionals and future leaders and promote their contributions to eHealth’s advancement across Africa.

Engagement of partners is critical too, such as professional bodies, with an important step being to work with Africa’s Public Health Associations (PHA). Developing Acfee’s eHealth curriculum will advance too with collaboration with Health Information Systems Program (HISP) and selected African and international universities, including New York University, Monash South Africa and Rome Business School for Masters degrees for Africans.

Finally, Acfee’s two landmark events will continue, with the eHealthALIVE broad stakeholder forum planned to run in Southern Africa and the East African Community (EAC) in 2017. AEF meetings of Permanent Secretaries and other health leaders will follow these, to extract the lessons from the eHealthALIVE platform and channel them into decisions by ministries.

Acfee’s relationships with African health ministries are growing, as are our efforts to collaborate with like-minded partners to expand stakeholder engagement to advance African eHealth.

Our shared goal is healthier Africans, in 2017 and beyond.

Chapter 1 of the WHO and Global Observatory for eHealth (GOe) publication Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable says “It has become increasingly clear that UHC cannot be achieved without the support of eHealth.” It describes eHealth’s foundations and sees a national eHealth strategy as a core. That 58% of countries have a national eHealth strategy is an important start.

Good components for these strategies are described as:

  • What citizens value and understand
  • The context of the health priorities
  • A vision
  • A plan of action for delivering the vision
  • Monitoring and evaluation
  • Stakeholder engagement
  • Governance
  • eHealth components of standards, legislation, technical and service delivery solutions
  • Finance
  • Human resources to deliver them.

Acfee’s African eHealth Forum (AeF) report in 2015, Advancing eHealth in Africa, identified some 60 long-standing eHealth challenges that need addressing too. These included connectivity, improving dependencies beyond healthcare, such as registration of births and deaths, integration with research, procurement, better risk management and cyber-crime. In 2015, the AeF concluded that “African countries’ successful, expanded eHealth investment depends on dealing with long-standing eHealth challenges.” Solutions are seen as comprising thirteen measures:

  • Strategies
  • Human eHealth capacity
  • Leading and managing complex change                          
  • Relationships with suppliers
  • Sustainability
  • eHealth performance
  • Health informatics
  • Business cases
  • Benefits realisation
  • Regulation and governance
  • Procurement
  • Medical Education
  • Country scale.

Evidence of eHealth’s performance and net benefits is sparse. eHNA has referred to numerous evaluations that show a range of studies with incompatible findings that range across eHealth’s success, its unexpected extra costs, modest benefits and financial disasters.

This year’s AeF report, Advancing eHealth 2016, identified five themes, one of which is National eHealth Strategies, and set out seven priorities as:

  • Cyber-security
  • Cloud computing
  • eHealth surveillance
  • Establish technical working groups for Interoperability (IOp) and support an IOp workshop and development programme
  • Develop eHealth curricula
  • Engage professional bodies
  • Collaborate with regional bodies.

Progress is underway and Africa’s regional bodies have an important role to play in eHealth’s development. They will need to expand their views beyond the WHO report contents to consider recent challenges to eHealth development, such as the growth in cybercrime and the need for countries to take effective countermeasures. For Africa, this will put extra strain on already stretched resourcing for eHealth foundations. National eHealth Strategies will need to be agile and well supported across local stakeholders to fulfill their important foundational role. 

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Image from the global eHealth observatory report 

The African Centre for eHealth Excellence (Acfee) has released its Advancing eHealth 2016 report. The report findings are that eHealth initiatives are expanding in African countries, though their impact on health systems strengthening and transformation, and ultimately their contribution to healthy Africans, is less certain.

The African eHealth Forum is where Acfee’s management team consults with its Advisory Board, industry partners and other stakeholders, to exchange their experiences of eHealth in Africa to find ways to support eHealth to strengthen healthcare and make Africans healthier. The second annual forum was in Sandton, South Africa on 8 and 9 September 2016. It followed the successful eHealthALIVE event.

During AeF, Acfee's Advisory Board identified five eHealth priorities. They are:

  • eHealth strategy
  • eHealth governance
  • eHealth regulation
  • eHealth cyber-security
  • eHealth impact.

The AeF believes that developing these will help eHealth to advance. They are discussed and elaborated on in the report and Acfee will be investing in moving each one forward.

eHealth in Africa still has a long way to go. The AeF report sets out some of Acfee’s contributions to moving it on. eHNA’ll be reporting on its progress.


The AeF followed the first annual eHealthALIVE Southern Africa conference, a broad stakeholder engagement platform for exploring eHealth's opportunities in the region. Read it's report here.

While South Africa has a national eHealth strategy, provinces have different starting points. At this year’s eHealthALIVE conference, Ms Thato Lekhu set out the Free State’s eHealth status for its five municipalities.

The Free State Department of Health (FSDoH) provides a diverse and interwoven healthcare programmes at different stages of maturity. These service areas start from basic healthcare, such as outreach teams, to specialised disciplines. Using eHealth to support these services should align with the complexities of each them is a core part of FSDoH’s eHealth strategy. A parallel goal’s to ensure that eHealth’s enabled with the bigger health and healthcare picture.

High speed connectivity is seen as linking the front and back ends. Front end content includes:

  1. Care-based surveillance with patient-level data in EMRs
  2. Information, Monitoring and Evaluation (M&E)
  3. Management dashboards and routine data for policy and decision makers
  4. Graphical User Interfaces (GUI)
  5. Access security
  6. User-defined queries
  7. Management reports.

The back end includes:

  1. Web-based application architecture
  2. Content management systems
  3. Central database, Structured Query Language (SQL)
  4. Cloud computing
  5. Data warehouse infrastructure
  6. Automated backup
  7. Data capture.

The main systems for patient information and research include:

  1. District Health Information System 2 (DHISs) database
  2. ETR.net
  3. Tier.NET
  4. Patient admission and billing (PADS)
  5. MEDITECH
  6. Pharmacy and other database systems
  7. Mosiac for oncology
  8. Occupational Health and Safety Information System (OHASIS)
  9. Picture Archiving and Communication System (PACS).

Current initiatives to enable the FSDoH eHealth strategy include:

  1. Connecting clinics using:
  • vSat
  • Microwaves
  • Distribution of 3Gs
  1. Some clinics have data initiatives with a minimum of 128k
  2. Tertiary, central and regional hospitals range from 512k to 2Mb.

Ms Lekhu’s clear that all these initiatives aren’t enough to run all systems simultaneously. More investment’s needed to deal with practicalities such as:

  1. Scheduled backups and patches or updates to run at night
  2. Data being depleted before month ends, hampering services
  3. Delayed email deliveries, followed by  telephone call confirmations
  4. Connectivity strategies need expanding to roll out the Integrated Patient Information System (IPIS)
  5. An improved integration platform for information systems
  6. More people with ICT skills and programmers
  7. Need for a single patient information system
  8. Projects to implement the National eHealth and mHealth Strategy
  9. More capacity to import patient data, information and clinical notes into new databases
  10. Inadequate funding
  11. Enhanced in house skills of employees, including data capturers and healthcare practitioners.

These are not exceptional just for FSDoH. Many health systems in many countries face equivalent challenges. The critical feature is dealing with them at pace that’s sustainable and successful. Ms Lekhu as three main recommendations to achieve them:

  1. A national driven eHealth implementation plan to guide provinces on when, where and how to invest
  2. A costed and funded business plan and conditional grant for implementing eHealth nationally
  3. Improved computer literacy for coalface officials.

These will benefit the whole of South Africa’s health system. They also have a resonance with other countries’ eHealth strategies. Implementing eHealth strategies looks set to be a recurring eHealthALIVE theme.

Completing a realistic eHealth strategy’s not an easy task. Senegal’s done it and published how it’s done it through the Knowledge for Health (K4Health) IntraHealth International project. The Senegal team identified nine lessons learned:

  1. Allocate sufficient time to develop a credible scientific document and anticipate the financial resources needed
  2. Start with a baseline evaluation or a situational analysis that includes reviews of existing eHealth projects and players
  3. Apply a consultative, participatory approach where key players with diverse expertise are brought together for brainstorming
  4. Refer to countries that have an operational strategic plan and learn from their model while taking socio-economic factors into account
  5. Assess infrastructure
  6. Ensure that your country has appropriate legal norms in place
  7. Establish a realistic activity calendar
  8. Seek high level support for the strategy
  9. Refer to the WHO/ITU toolkit for guidance and tools.

These are drawn from a Senegal setting of many eHealth initiatives intended to strengthen its health system. Needing to strengthening coordination and collaboration among all health system stakeholders, including ministries, partners, donors and the private sector, the Ministry of Health and Social Action (MOHSA) started working on national eHealth strategy in 2014. Early in 2015, with support from the United States Agency for International Development (USAID), the WHO, and the K4Health Project, MOHSA coordinated its eHealth Strategic Plan.

The process was:

  1. Form a temporary technical committee with representatives from government and key implementing partners and donors to co-ordinate the process through regular meetings
  2. A desktop review of other countries eHealth strategies and processes used to develop them
  3. A situational analysis from interviews with government bodies, partners, and the private sector
  4. Inclusive and participatory working with stakeholders
  5. Create a dynamic national eHealth registry to record and update eHealth initiatives to support government’s decision making and unveil new business opportunities for the private sector
  6. Set critical success factors for developing Senegal’s eHealth strategy, including strong governmental engagement and support, commitment of partners for collective action, good financial backing, and strong leadership from the Office of the Director General for Health.

While the process was inclusive and participatory, the scope of participation was limited to government and some implementing partners. This made the process more manageable. WHO provided technical assistance.

Senegal’s recommendations to ensure the eHealth Strategic Plan is useful include:

  1. Establish an institutional framework to organise and coordinate all eHealth interventions.
  2. Establish a strong national steering committee that stimulates action and integrates M&E
  3. Ensure a multi-sectoral approach, with all services and directions in MOHSA engaged in implementation and M&E
  4. Integrate eHealth throughout the hierarchical structure of the health system, a health pyramid, and consider decentralising to a focal person supervising eHealth systems at national, regional, and district levels

Other recommendations deal with:

  1. Finance and human resources
  2. Dissemination
  3. M&E
  4. Successful strategy implementation
  5. Monitoring implementation
  6. Approaches by other countries planning an eHealth strategy.

Senegal’s strategy was completed in August 2015, six months after stakeholder engagement began in February 2015. It’d now be valuable if K4Health sponsored a commentary on progress on implementation and M&E, two activities many countries in and beyond Africa find challenging.

While many mHealth initiatives are local and spawned by enthusiasts, it’s essential that they have a strategic context. At this year’s eHealthALIVE conference, Peter Barron, mHealth Advisor to South Africa’s National Ministry of Health set this out for South Africa’s national health system. Five examples are:

  1. MomConnect, to promote the health of mothers and children
  2. NurseConnect, to support nurses’ knowledge and practices
  3. mHealth apps for clinicians
  4. Medicine adherence for patients
  5. Stock control for clinics to minimise stock-outs.

MomConnect’s a two-way communication service. It sends regular, relevant information in the form of SMSs to pregnant women to help them take more responsibility for their and their babies’ health. Mothers can also provide feedback on services they’ve received that’s used to improve healthcare quality, so strengthen the health system. Feedback’s structured as:

  1. A service rating system for antenatal clinic visits
  2. A compliments system
  3. A complaints system for issues such as long waiting times, health workers’ inappropriate behaviour and drug and dietary supplement stock-outs.

NurseConnect was piloted between January and March. Scale up started in May. It aims to support and empower nurses and midwives by:

  1. Allowing them to use their cell phones free of charge to receive relevant information to help them improve their performance in maternal and child health
  2. Enabling them to provide feedback and seek advice about their work and work environment
  3. Enabling them to set up learning and support networks.
  4. In four months, some 8,000 nurses have registered to use NurseConnect. The number of users’s expected to increase steadily.

mHealth apps include:

  1. Primary Healthcare (PHC) guidelines, including TB
  2. Help clinicians treat patients correctly, safely and in compliance with best evidence available
  3. Algorithms to help clinicians who plug in variables.

Medication adherence for patients:

  1. Allows patients to input their medication details
  2. Provides daily alarms as reminders to take medicines
  3. Keeps an overview of missed medication with green and red days
  4. Produces graphs of adherence
  5. Can link to a central database so that overall adherence is monitored remotely and provides information about overall compliance rates to direct compliance initiatives.

Stock control at clinics is built on an mHealth app that minimises stock outs by:

  1. Allowing central monitoring of essential drugs at clinics
  2. Providing an early warning system of potential drug shortages
  3. Enabling drug stock transfers to ensure equitable distributions
  4. A learning experience about stock management for clinic staff.

From this achievement, Peter Barron has considerable ambitions for the future. He sees progress so far as “Scratching the surface.” He sees big opportunities as people engage more with their mobile devices and spend more time interacting with them than they do with their partners. This opportunity’s enhanced by the younger generation who will always be much more techno sophisticated than their elders. As smart phones become the norm, and data and connectivity becomes cheaper and more readily available, Peter Barron’s personal ambition’s to be a fly on the wall in five years-time. Many of us would like to be on the same wall.

There’s a lot of eHealth innovation underway in African countries to transform our experience of healthcare and how we stay healthy. In my home country, South Africa, the Health Information Systems Programme of South Africa (HISP-SA) makes an important contribution, extending from its DHIS health data platform, now in use in 46 countries, to projects stretching from building mHealth apps, to training and support to help public health and facility managers take sound decisions.

It’s a foundation for expanding eHealth’s health strengthening role for the future, which is a strategic goal for HISP-SA and HISP entities around the world. There’s regular collaboration between country teams to move this vision forward, with significant support from HISP-SA.

HISP-SA meets a growing demand for eHealth expertise and services. In the last five years it’s expanded from a team of twelve people to now over one hundred. They cover a range of skills across public health, informatics, data management and computer science.

I’ve been asked to help lead HISP’s ICT strategy and its implementation. It’s a Chief Technology Officer role with a team of analysts, software developers, data specialists and ICT infrastructure experts. Everyone in HISP-SA’s dynamic and experienced team has a valuable contribution to make to the way ahead and to guiding HISP-SA to grasp the numerous eHealth opportunities across Africa and deal with their challenges.

I now work alongside well-known eHealth and public health personalities, such as Vincent Shaw, Gugulethu Ngubane, Calle Hedberg, Phumzile Zondo, Mohammed Jeena and Christa van den Bergh. An essential activity’s engaging closely with former colleagues and government eHealth leaders, including recently appointed National Director of Health Information Systems, eHealth stalwart Mr Mbulelo Cabuko, his colleague Julius Nkgapele, their Chief Director Ms Thulile Zondi and their teams.

Our relationship with provincial and district health is important too, to boost using information to improve health experiences at the point of care, for patients and health workers, and with key population groups.

HISP-SA’s priority is to support South Africa government’s health information systems. They exist to secure and support how South Africa delivers better health for all. It’s an honour to be part of this endeavor. I look forward to what we will accomplish during our time together.

It’s another eHealth step for Rwanda. An article in the New Times says Rwanda’s Ministry of Health has signed a Memorandum of Understanding (MoU) with the Republic of South Korea. The aim’s to improve technology in healthcare, including telemedicine, Hospital Information Systems (HIS) and ICT-based medical services. The MoU enables collaboration on eHealth between Korea Telecom (KT), Yonsei University Health System, including Severance Hospital, and University Teaching Hospital of Kigali (CHUK).

At a media briefing, Kwon Deok-cheol, the visiting Korean Deputy Minister for Health and Welfare, said eHealth’s now an effective tool for sharing information needed for healthcare and controlling Non-Communicable Diseases (NCD). “eHealth would be very crucial in providing information, especially now that Rwanda has potential to expand modern health services across the country. Through working together, information between the two countries will be shared.”

Rwanda’s Health Minister, Dr Agnes Binagwaho, said technology will be distributed across all levels of the health sector so everyone benefits. Her vision’s to “Use technology right from the rural areas to the national level that is how we can manage e-Health. Although we still have a long way to go in terms of improved management, access to information, advice from health personnel and distance towards health care facilities, this arrangement is one of the opportunities for us to improve.”

As eHealth expands, it becomes more complex and challenging. Collaboration is an increasingly constructive approach. Rwanda’s collaborative strategy offers a model for all African countries.

African countries are producing National eHealth Strategies. In the last two years, announcements have come from Burundi, Mauritius and the Democratic Republic of Congo. Countries with strategies already in place include Egypt, Ghana, Kenya, South Africa, TanzaniaZimbabwe and others. Some have taken a step further and developed complementary strategies, such as South Africa's 2015 mHealth Strategy. You can follow the hyperlinks above to find a PDF of each document on the Resources tab of eHNA’s country pages.

Having a strategy’s a big step forward. It fulfils resolutions made by ministers of health at the sixty-sixth World Health Assembly in 2013. It shows that the countries see a valuable role for eHealth in their health systems strengthening and mapping out a way forward to realise eHealth’s benefits.

A good strategy goes further, recognising that health systems need more than strengthening to provide the health and care that citizens need. Despite limited resources, health systems need to transform by finding innovative ways to reverse trends of a rapidly rising curative burden and big, continuing population growth, perhaps as much as 3% a year.

At Acfee’s African eHealth Forum (AeF) in July 2015, senior eHealth leaders from several countries identified more than 60 long-standing eHealth challenges that need fixing before eHealth can make a big impact. The list, described in Advancing eHealth in Africa, was longer, and more demanding than most people expected. These need addressing as part of an annual investment programme that initially stops the challenges expanding, and achieves a steady shrinking of their constraining impact.

Expanded eHealth leadership, and eHealth capacity for skills and knowledge in the health workforce are important and continuing challenges. These we identified in 2009 by the Commonwealth Secretariat in its support programme for eHealth strategies. In a series of workshops, African countries working on their eHealth strategies showed that they needed to develop and achieve new organisational contexts to pursue their eHealth goals effectively. Without them, the important eHealth technicalities such as interoperability, architecture, standard and connectivity would not realise their benefits fully. There is still much more to do.

Over the last few years, Acfee’s been helping Africa’s health systems to construct their organisational contexts. The AeF report confirmed that enhanced eHealth leadership and workforce capacity are essential. Their components extend across activities that include:

  • Engagement with health professionals
  • Realising benefits for healthy Africans and better healthcare
  • Transforming healthcare delivery and health systems
  • Sustainable health strategies
  • Rigorous business cases for eHealth investment decisions that implement strategies
  • Effective procurement
  • Sustainable financing models
  • eHealth regulation
  • Responding to growing challenges, such as cyber-threats
  • Responding to new eHealth opportunities and priorities, such as Big Data and surveillance.

These are not easy to achieve. eHNA has numerous reports of countries that have struggled with many of these, and are still struggling. Putting the health ICT technicalities into the mix makes it even more demanding.

Where to start and what path to follow are good questions. The first step to success is recognising that it’s a long, slow road with no end. Health workers need new eHealth skills and knowledge that go beyond the health ICT technical skills that health informaticians need as specialists.

The National eHealth Strategy Toolkit, published by WHO and ITU, provides an overall approach and lots of detail to help countries plan the way forward. 

Acfee is developing programmes with eight African universities to begin the journey, and will be reviewing these with African health leaders at events such as the African Health Summit and the next African eHealth Forum.

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Image from the Toolkit