Throughout its evolution, telecommunications has radically changed traditional ways of doing business and connecting people, and we have seen many sectors transformed completely by the capabilities and reach of telecoms. One of the sectors positioned to experience the next wave of transformation is health care. Applications for individuals, doctors, hospitals and communities have the potential to dramatically improve health and provision of care globally. Here, Dr. Najeeb Al-Shorbaji, the director of knowledge management and sharing at the World Health Organization, shares his insights into the current success of eHealth initiatives, the challenges and opportunities ahead, and the need for investment to further improve health in remote areas of the world.
First, I'd like to clarify these terms as we define them at WHO. We describe terms such as mobile health [m-health], telemedicine, and tele-health as eHealth applications. eHealth was defined by the World Health Assembly Resolution in 2005 as "the use of information and communications technology in health". Mobile health is the use of mobile technology to support health care. Telemedicine can incorporate other technologies, including the Internet, the satellite, the fixed-line telephone or radio. Telemedicine is a much more inclusive concept than mobile health, but eHealth is used by WHO as an umbrella term to cover all these concepts.
Mobile health is not reaching remote or rural areas, which are in real need of these services. Remote places have fewer human resources and facilities to serve their communities and transportation is often difficult. We are trying to promote the concept that instead of making people move to get health services, move health services through better delivery of health information. In that way a doctor or nurse can gain access to resources from centres of excellence located in other places.
There are problems with this, of course. I see infrastructure as one barrier for not achieving the full potential of m-health. Looking at maps of countries in terms of telecommunication infrastructure, many urban areas are better served than rural and remote areas because of sheer numbers of people, which telecommunications operators base their business models on.
The other barrier is financing. People like to invest where there is a faster, more positive return— which is typically not in rural areas. Investment is something that we need to work on. The other barrier is the governance of m-health and its applications. There are numerous legal, ethical and standardisation issues that need to be worked out to allow for more universal access to mobile technology and, as a result, to mobile health services.
Yes, we have just made an inventory of mobile health projects in Africa. We have identified about 400 projects there, which look at how to deliver health care or how to collect health data from the field.
There are some excellent examples of how mobile phones can help people with tuberculosis [TB]. TB patients have to take their medication at certain times for a specific duration or they risk developing drug resistance. One mobile health application will send an SMS reminding patients when to take their medication. The patients then confirm that they have complied. For those who have problems with diseases such as diabetes, technology can provide advice on diet, exercise and overall lifestyle.
Using the mobile phone to deliver health information in support of health care or to remind patients of their medication or to collect data on health situations requires policies, investment, partnerships and training. One striking example is an application that can help patients to identify whether a medicine is counterfeit. A code provided by a pharmacy can be sent to a database via a mobile phone to allow people to check whether a drug is genuine. Counterfeit drugs are a major issue in Africa and many Asian countries.
There are other examples: in Bangladesh approximately 30 million women are provided with mobile connectivity throughout their pregnancies.
Unfortunately, so many of these mobile health projects are pilots, which run on a limited scale for six months or a year or they are short of funds. We have not come to a stage where a mobile health project is a national one and funding or sustainability is guaranteed for two or three years. We haven’t seen many projects in which m-health is integrated into the health care system; it is still something that is done in parallel. What we have seen is that mobile health can improve the quality of health service; it reduces cost of delivery and yet is not fully integrated in health care systems. It can deliver information faster and help patients to get timely, accurate information in collaboration with their health care providers and associated institutions.
Helping people with poor reading skills to get information is a big challenge.
The good news is that researchers and developers from both academia and the private sector are working on this issue. I have seen applications where illiteracy is addressed by using voice messaging. There are also applications that aid people with visual impairment by enlarging the text or using animation or graphics to guide people on matters such as how to take certain drugs.
One of the biggest challenges is to ensure that the knowledge gap in the world is not increased as a result of the digital gap. We want to make technology available in a way that will improve literacy, access to knowledge, the quality of information that people are accessing and in a language that is appropriate to them. We have heard about an application that makes it possible to make a phone call in your language and the person receiving can listen to that message in theirs. The translation process allows people to bridge the language or literacy gap.
I hope that technology companies will consider society in its totality and not deprive any part because access is difficult for them. Software developers need to help communities to bridge the knowledge gap.
According to our global eHealth survey, the most commonly reported m-health initiatives in the world are for emergency and disaster situations, health call centres or help lines, surveillance programmes, and voice and text messages to achieve treatment compliance. A number of countries reported that mobile health was helping with HIV/AIDS treatment and follow-up. M-health involves collecting data and reaching out to communities with high-quality information.
Telecommunications technology is fantastic for data gathering, for surveillance, for epidemiological surveys and the like. However, telecommunications is about twoway communications. It is equally important for technology to be able to send back data that has been analysed so that people can use it to improve health education, health promotion, or for distance learning, tele-consultation, etc. In other words, data collected about people's health through a technology should come back to them as knowledge through appropriate technology.
We have a fantastic example of collaboration between the University Hospital in Geneva, Switzerland and WHO for providing telemedicine in Africa. Fifteen Francophone African countries are provided with services for tele-education, e-learning, second opinion, group discussions, and so forth on a monthly basis using the Internet. One of the major problems in Africa is a lack of doctors, nurses and other health workers. This service—and many other programmes—provide a means of sharing medical knowledge. WHO has been sponsoring a programme called 'Implementing Best Practices Knowledge Gateway'. The concept is simple: create a virtual network of thousands of professionals worldwide to share experience and knowledge and learn from each other.
Around 4.6 billion people have access to a mobile phone and 1.7 billion have access to the Internet. Can the telecommunications sector and other companies develop a more cost-effective and better way of bringing mobile Internet to remote areas? We know that 67 people out of 100 have a mobile. We know that 26 people out of 100 say they have access to the Internet. However, when it comes to Africa, only four percent of the population has access to the Internet. How can we bridge that gap?
One challenge is to figure out how to reduce the cost of smartphones so they are available to more people. The second challenge is to make them simple to use. We don’t all need sophisticated devices. There are many applications that can run on less sophisticated technology. It’s a challenge in terms of who will pay for that, but my feeling is that we all have to work together. We have to build a public-private partnership. A target within one of the United Nations' Millennium Development Goals specifically asks for publicprivate partnerships in the area of information technology and telecommunications. This is not necessarily the responsibility of the government or the private sector, UN agencies, NGOs or donors. It’s the responsibility of everybody to recognise the need to invest.
Definitely. One important function that we have is to help countries to set policies and strategies to create the right governance for introducing eHealth or m-health initiatives. This is through standardisation and by building capacity in people. We work with governments to identify their needs and help to resolve them by reaching out to companies, partners or donors. One of the major issues in many countries is that many projects are not linked. There is an absence of a national strategy or a legal framework in many countries. We work with governments and with companies to advise what interoperability standards would provide confidentiality, privacy and data protection for transfer of data from one record to the other, from one hospital to the other and from one region to the other.
What we see in many places is that hospital A has one system, hospital B has another and when a patient is in an emergency in one of the two hospitals, the patient's records are not available. The hospital has to gather patient information again, which is expensive and can result in mistakes. We are advising countries how to assess their needs and ensure that their information systems fit their requirements, rather than bringing in a solution and looking for a problem to match it up to.
People ask why the health care sector is late in embracing information technology. I hear people asking why can’t we deal with health data in the same way as we deal with the ATM? You go to a machine, insert your card and get your money. But a health transaction is more complicated than financial transactions. It’s about individuals—the information collected is more complex and requires different standardisation. It requires a different way of working and a different technological design. We are still short of innovation for health applications that fit health needs. Take the keyboard, for example. It’s not designed for doctors. Doctors need a different way of interacting with the computer in which their tasks are supported through technology. Look at relational databases. They are designed basically for finance, or banking, or human resources but not to record health conditions.
How can we improve software and hardware design to reflect the way the health sector works? There are applications like voice recognition, for example, by which the doctor can dictate a diagnosis or a prescription which then goes into the medical record as a transcript. But somebody has to go back and make sure that there was no misinterpretation. That means additional work. We dream of true innovation in health technology instead of adapting technologies used in other industries. That only comes through investment and research to gain a better understanding of the needs of this user group.
I believe strongly that investing in making knowledge and information available to people will help them to become healthier and more productive. Investment in health technology should not be something that we cannot do because it’s costly. The long-term return on investment is there; there are savings, improvements and efficiencies. In a citizen-centred health care system, technology is an enabler. Technology companies must understand that they are part of a social-economic movement in terms of improving the quality of life.
Of course the government has a major role to play. However, I think it is a shared responsibility with the private sector and shareholders. We have to understand collectively what is good for the community and do it. I understand the need of the private sector to make a profit, but I strongly believe that this investment is good for these companies if they do it in a way that supports equity. Many ICT companies have their own philanthropic arm. I hope more of these foundations, and the companies themselves, will recognise their social responsibility to work with governments to make these technologies more affordable, and more accessible.
Dr. Najeeb Al-Shorbaji has been working as director, department of knowledge management and sharing, at the World Health Organization Headquarters (WHO/HQ) in Geneva since September 2008. Prior to that he held the posts of information scientist, regional adviser for health information management and telecommunication and coordinator for knowledge management and sharing for WHO Eastern Mediterranean Region.
Dr. Al-Shorbaji's portfolio covers WHO publishing activities and programmes, library and knowledge networks, eHealth, and WHO Collaborating Centres. He is a member of a number of national and international professional societies and associations specialising in information management and health informatics. He has written over 80 research papers and articles presented at various conferences and published in professional journals. Dr. Al-Shorbaji has held a PhD in information sciences since 1986.
For more information, visit the organisation's website at www.who.int.