WHO (10)

Africa is using social media for health. Insights are in Chapter 7 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. WHO Global Survey 2015 is the data source.

The main theme is that social media provides an important means to convey messages for health organisations and receiving and sharing information for individuals and communities. A downside is that there’s still plenty to do to understand how its potential can support Universal Health Coverage (UHC).

Key findings include:

  1. Nearly 80% of countries say healthcare organisations use social media to promote health messages
  2. Nearly 80% say individuals and communities use it to learn about health issues
  3. In over 62%, individuals and communities use social media to run community health campaigns.

While, as usual, Africa lags behind the global position, its social media use is relatively high. Health organisations using it to promote health messages as a part of health promotion campaigns is not too far below global rates. Individuals and communities using it to learn about health issues is close to global rates too. Other uses tail off.

It reveals two goals for African countries; do more and find the best ways to use social media. eHNA finds, collects and posts on research and commentaries on social media. Some social media makes no difference to health, for some, it’s not clear what difference it makes, for others, it’s effective. All findings provide valuable lessons for Africa’s health systems’ endeavours to use social media for healthier Africans.

Africa’s eHealth legal and regulatory framework is behind global trends, as eHNA has reported. More insights are provided in Chapter 6 of the WHO Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable. The report's data source is the WHO Global Survey 2015.

Key findings include:

  • Slow but steady development of general eHealth regulation, with 33% of countries with  specific policies or legislation to define medical jurisdiction, liability or reimbursement of eHealth services
  • About 47% have legislation to promote safety, quality and standards of health related data
  • About 78% have health data privacy legislation and 55% have legislation to protect the privacy of electronically patient data. They’re up from 73% and 31% since 2010, so a big step up for eHealth data laws.

The survey focused on EHRs, which are dealt with in detail in Chapter 5. They are seen as the basis of eHealth systems, so a good indicator of general eHealth regulatory framework maturity. Consequently, countries that don’t have EHRs aren’t covered.

Africa’s overall position’s about half the global average. Catching up is not easy, Much of the current eHealth regulation’s generic, such as data protection laws and telecommunications regulation. It takes time to find a slot in countries' legislative programmes. eHNA posted that Angola took some five years to complete its data protection laws. This’s a typical timescale that other countries have said is needed to move eHealth regulation on.

The challenge is exacerbated because eHealth regulation extends well beyond EHRs. Examples are data transfer and communication using mHealth services and new regulatory aspects such as eHealth governance and cyber-security. African countries will be unable to set up comprehensive regulations for all eHealth settings in the medium term, so setting eHealth regulation priorities is crucial.

From these, eHealth laws and regulations are needed alongside finance and resources for a regulatory body and compliance reviews. These have to compete with finance and resources for expanding eHealth services and emerging demands such as cyber-security and human capacity building. An important question for Africa’s how much eHealth regulation’s needed?


Image from the WHO report

EHRs are one of eHealth’s building blocks. WHO Global Survey 2015the data source for the WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable, provides insights for Chapter 5.

Key findings include:

  1. Steady growth in adopting national EHRs over the last 15 years
  2. About a 46% global increase in the past five years.
  3. Over 50% of upper middle and high income countries have adopted national EHRs
  4. Much lower adoption rates in the lower middle and low-income countries at 35% and 15%
  5. Most national EHRs integrate with laboratory and pharmacy systems at 77% and 72%, with Picture Archiving and Communication Systems (PACS) at 56%.

Africa’s national EHRs match the low-income rate. Their integration with other information systems is lower than the adoption rate, so well below the global position. While some of the shortfall may be due to the definition of countries’ EHRs not matching WHO’s survey definition, so possibly understated, as the report mentions, it’s still a big gap.

Catching up needs African countries to step up their investments. It also needs investment barriers to EHRs removing. WHO says these include lack of funding, infrastructure, capacity and legal frameworks. For Africa, parallel investment’s also needed in laboratory, pharmacy and imaging services and cyber-security, eHealth governance, business cases and M&E.

Catching up alone isn’t a good investment goal. Adopting EHRs at a sustainable, affordable pace that results in healthier Africans and enables health professionals to improve their contributions are best.

Both health and healthcare rely on intensive, continuing learning. Reaching everyone who needs it’s challenging for African countries. While eLearning can help, Africa’s trailing global trends. eLearning data from WHO Global Survey 2015the data source for the  WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable, provides insights for Chapter 4.                                                                                              

It found at least two thirds of responding Member States use eLearning for health science education, both pre-service education and in-service training, with Africa at 48%, so about 70% of the global average. Putting this outlying performance in the context of healthcare spending per head shows it as a considerable achievement.

Africa’s average healthcare spending per head’s some US$145, about 14% of the World Bank global average of about US$1,061. The highest’s about 62%, the lowest less than 2%. WHO’s eLearning score of 70%’s well above these, indicating a relative high priority accorded to eLearning in a stringent resource context.

A global eLearning profile’s:

  1. Medical students education at 91%
  2. Doctors education at 84%
  3. Pre-service education at 80%
  4. In-service public health education at 68%.

Five barriers to eLearning programmes supporting Universal Health Coverage (UHC) are, lack of capacity, availability of courses, human resources, finance and cost-effectiveness evidence. WHO’s report says evidence shows that eLearning for health professionals’ education is effective or more effective than traditional teaching. This offers a good case for advancing eLearning if Africa can ease through the other barriers.

French and English speaking African countries have long associations with telehealth. Réseau en Afrique Francophone pour la Télémédecine (RAFT) Project involved Geneva University Hospital and Health On the Net Foundation in developing a network for eHealth in Africa. It started in 2000 and is now across four continents.

Telehealth data from WHO Global Survey 2015 provided insights for Chapter 3 of the WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable. The report deals with five telehealth types:

  1. Teleradiology
  2. Teledermatology
  3. Telepathology
  4. Telepsychiatry
  5. Remote patient monitoring.

A country average was 3.7 telehealth programmes. At about 3.3, Africa had slightly fewer, about 90% of the global average. For the five telehealth types, Africa’s teleradiology in about two-thirds of countries has a score of some 60%, below the global rate of 75%. The other four types are below 45%, with telepsychiatry the lowest, about 20% of teleradiology’s rate.

Telehealth evaluations are increasing in number. Criteria used to evaluate government-sponsored telehealth programmes were:

Programme acceptance by providers
Programme acceptance by target groups
Cost-effectiveness for providers
Health outcome
Cost-effectiveness target groups

Comprehensive evaluation using Cost-Benefit Analysis (CBA) could combine all these perspectives. It could also include efficiency and provide a direct link with telehealth financing. Global perspectives of barriers to telehealth investment may not match Africa’s, especially telehealth finance and infrastructure for connectivity:



Since telehealth emerged on the scene, technology’s changed. The Internet and mHealth have created new and wider opportunities. Initiatives like Figure 1, described in an eHNA post, are changing its scope and range, and offer Africa’s health systems greater participation. 

Africa’s eHealth initiatives accord an important role for mHealth services. There’s a very wide range of mHealth projects, but still plenty to do. African countries scored between 50% and 60% in the mHealth section of the WHO Global eHealth Survey 2015the data source for 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. Its key findings for Chapter 2 on mHealth are:

  1. 87% of responding countries say they’ve at least one mHealth programme
  2. 80% of the low income countries say they’ve at least one mHealth programme
  3. 91% of high-income countries have at least one mHealth programme
  4. More mHealth programmes operational for at least two years with finance for at least two more
  5. Only 14% of countries have an evaluation of a government-sponsored mHealth programme.

These numbers say nothing about the utilisation or coverage of the programmes. The evaluations say nothing about their costs, benefits, net benefits or timescales needed to achieve net benefits.

Africa’s average performance is below the average for low income countries. While this seems to indicate that more can be achieved, extra spending needs pursuing with considerable care. eHNA post about the American Medical Association (AMA) Executive Vice President and CEO’s view seems relevant - that it’s vital to separate digital snake oil from the useful, and potentially magnificent, digital tools, and quell the undesirable digital dystopia that doesn’t improve health, healthcare or make it more efficient. He includes Ineffective mHealth apps of questionable quality.

While his vocabulary’s exotic, he emphasises an important theme of good mHealth investment. It’s challenging to produce rigorous mHealth business cases when the evidence is from 14% of countries. It’s not much more than the 12% found in 2010. African countries comprise about 18% of these, with three evaluations. eHNA has posted on several research findings that show that much of mHealth benefits are questionable or short term. It’s essential that mHealth business cases are explicit and about the net benefits expected, then followed by evaluations to add to mHealth knowledge.

mHealth’s a multifarious term. It includes fitness wearables. Chapter 2 has 14 other types:

  1. Health call centres                                             
  2. Appointment reminders
  3. Telehealth                                                                
  4. Community mobilisation
  5. Awareness raising                                              
  6. Emergency access
  7. Emergency management                               
  8. EPRs
  9. Patient monitoring                                             
  10. mLearning
  11. Health surveys                                                      
  12. Surveillance
  13. Treatment adherence                                      
  14. Decision support systems.

Four future mHealth themes are seen as:

  1. Evaluate implementation and outcomes
  2. Develop regional and global networks to share mHealth knowledge
  3. Determine the best areas for mHealth to help adoption and local innovation
  4. Researchers, health authorities and global entities promote mHealth indicators.

Africa can lead on these. It needs the information.

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. 


Image from the global eHealth observatory report 

Sustainable eHealth is a goal for Africa. Affordability is a crucial component. WHO Global Survey 2015the data source for the WHO and Global Observatory for eHealth (GOe) publication eHealth Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable. 

Chapter 1 provides insights. It shows a profile of four main sources. Africa’s is very different, confirming one of its biggest challenges, securing sufficient sustainable eHealth finance. The comparison is:

The telling challenge is that Africa’s reliance on donor and public finance is nearly as much as the global rate for public finance. It’s widely recognised in Africa that this is not sustainable enough, but realigning it to match the global profile more closely isn’t realistic in the medium term.

Instead, a strategy of seeking donor support for non-recurring resources that matches Africa’s eHealth priorities seems a better option. This isn’t easy either. Africa’s eHealth needs investment in a wide range of capacities and infrastructure to expand and deepen its foundations. This can be less attractive to donors who have their own priorities that are often for more visible and tangible projects.

The other important feature is that PPP is close to the global average too. PPP often has high operational costs and limited risk sharing and almost no risk transfer. It’s attractive to start up big scale eHealth programmes, but its annual operating costs can be extremely rigid and onerous. If WHO’s survey shows Africa moving towards PPP instead of the more demanding initiative of expanding public finance, it signals a need for rigorous financial and risks assessments as part of a robust business case before proceeding.  

eHNA’s posted on an extreme example of a crashed PPP. The health system believed it had transferred the risk, but the legal system didn’t see it that way.


Image from the global eHealth observatory report 

WHO’s third global eHealth observatory report is a meaningful update on global developments and trends and poses important challenges for African countries embracing eHealth for their health systems’ transformation.

Helping to review content for the report, along with colleagues from the WHO eTAG and many other eHealth experts, I was exposed to the considerable work underway globally, and the extraordinary teams helping to explore eHealth's role in improving our health and health systems.   

At Acfee, we're especially interested in the implications for Africa. eHNA will post separately on each of the eight chapters in WHO’s report. Each post will take an African perspective to offer an assessment of features of its eHealth and Universal Healthcare Coverage (UHC) opportunities and constraints.

It’s widely recognised that Africa has a considerable healthcare deficit and high disease burden. The combination creates a constant, long-standing struggle and much more than the policy and management euphemism of a challenge. Africa’s average healthcare spending per head’s some US$145, about 14% of the World Bank global average of about US$1,061. The highest’s about 62%, the lowest less than 2%. These aren’t adjusted for the high disease burden, or the difficulties of providing healthcare to extremely remote communities. It’s unrealistic to expect Africa to achieve the huge productivity increase needed to provide UHC, provide the extra cash and capacity needed, or a combination of both over the medium-term.

Aiming to achieve UHC in this economic context is a lot more than demanding. The 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.” I've heard similar sentiments expressed by African colleagues such as Liberia's Luke Bawo, speaking about his country's response to Ebola and Acfee's Ousmane Ly, describing the eHealth initiatives he's leading in West Africa.

It's a reasonable proposition, but for Africa, it’s not enough for all people to receive the high-quality health services they need without suffering financial hardship.

Africa’s UHC solutions are a combination of:

  • Substantial and rapid economic growth
  • Significant, sustainable increase in finance for health and healthcare
  • Converting the extra cash into sustainable real healthcare resources, including all types of healthcare workers, medicines, medical and surgical supplies and extra and better facilities
  • Proven eHealth, especially proven mHealth.

WHO’s report says 90% of eHealth strategies reference the UHC objectives or its key elements. This is for the 58% of countries that have eHealth policies or strategies, so about 52% of all countries. For Africa, 39% of countries report having an eHealth strategy, of which 58% have UHC objectives, so about 23% of countries. Consequently, Africa’s eHealth role in UHC isn’t specified formally yet, indicating the need to enhance or replace them.

Other limitations are that Africa’s eHealth strategies seldom integrate with related economic growth, healthcare finance and real resource strategies and plans, and none have sustainable, longer-term horizons. Africa’s eHealth strategies need upgrading for other factors either understated or not referred to in the report. Four are:

  • Effective, consistent patient unique ID
  • Interoperability (IOp), which is in its infancy across Africa
  • Cyber-security, which is becoming an increasing global challenge
  • eHealth governance, not yet well developed across Africa.

Acfee’s African eHealth Forum (AeF) report included these in its identified priorities. Acfee will release commentaries on cyber-security and eHealth governance early in 2017. It will also be able to offer health systems opportunities to participate in developing IOp use cases using a globally recognised methodology and standard.


Image from the global eHealth observatory report 

The World Health Organization (WHO) is building an arsenal of digital tools to support patients and healthcare workers. It already has an e-pocketbook app for children and recently released an mHealth checklist for the reporting of mobile health studies. Their latest mobile app supports healthcare workers in their fight against Zika, a fast-spreading virus that the WHO has declared a global public health emergency. The Zika app is a medical app for physicians and health professionals to reference for the latest information about Zika, says an article in iMedicalApps

The virus is an emerging mosquito-borne illness that was first discovered in the 1940’s. It is spread via the bite of the Aedes mosquito, though we now know the virus can also be spread via blood and semen. 

Although outbreaks in the past in Africa and Pacific countries had noted microcephaly, the current outbreak that started in French Polynesia and Brazil has brought the proposed microcephaly link to the forefront. The WHO predicts that over 2,500 babies in Brazil will be born with microcephaly attributed to Zika.

The virus has spread rapidly throughout the Americas. The Centers for Disease Control ahs reported says there are now cases in over 40 countries and territories. Zika’s also now reached Africa’s shores as numerous cases in Cape Verde, off Western Africa, has been reported in eHNA. 

Currently there are very few medical apps on Zika, which is why the WHO Zika app is a welcome addition. The Zika medical app has three main modules: general information, health care workers, and news. Each one has many sub topics, ranging from symptoms to transmission to prevention. The healthcare worker section contains all of WHO’s technical guidance, ranging from birth defect surveillance training to prevention through sexual transmission. The medical app contains numerous WHO graphics, PDF’s and videos along with the most current Zika news. 

It’s a crucial tool for healthcare workers. The app’s free, available in English, French, Spanish and Portuguese and provides detailed content on the Zika virus. Its life-saving information and news section will ensure healthcare workers are familiar with the latest developments and spread of the virus, allowing healthcare providers and policy makers to track its spread and make better informed decisions. It’s essential for Africa’s health systems.