Appendix E
E-Health and the HIV/AIDS Epidemic: Using Technology to Support U.S. Workforce Expansion and Local Capacity Building in PEPFAR Nations

Holly Ladd and Rebecca Riccio

SATELLIFE

SUMMARY

The vast scope of the HIV/AIDS pandemic has generated an unprecedented need for medical services in low-resource countries, taxing already over-burdened and understaffed health care systems. As the World Health Organization (WHO) reported at a 2002 joint meeting with the World Bank in Addis Ababa:

There is an emerging crisis of health manpower in Africa. The situation threatens to defeat the efforts of African governments, private health care providers, NGOs, and donors for health improvement. Training programmes unsuited to changing health conditions, inadequate cooperation among the many parties concerned, and the losses of staff to opportunities outside Africa risk making Africa’s health care facilities barely able to function for lack of qualified, motivated doctors, nurses and other health workers. This situation is made even worse by the AIDS epidemic, which reduces further the availability of trained health workers by staff deaths and increases the demand for health care.1

To address the urgent need for more health workers, the President’s Emergency Plan for AIDS Relief (PEPFAR) calls for the placement of U.S.

1  

WHO Report at Building Strategic Partnerships in Education and Health, a WHO/World Bank Meeting, Addis Ababa, January 2002, as reported by Ntiro, Simba, et al. in Information and Communication Technologies and Continuing Medical Education in East and Southern Africa, Report of a Conference held in Moshi Tanzania, 8–10 April 2003, Research Report 17, June 2003. http://www.ftpiicd.org/files/research/reports/report17.pdf.



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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Appendix E E-Health and the HIV/AIDS Epidemic: Using Technology to Support U.S. Workforce Expansion and Local Capacity Building in PEPFAR Nations Holly Ladd and Rebecca Riccio SATELLIFE SUMMARY The vast scope of the HIV/AIDS pandemic has generated an unprecedented need for medical services in low-resource countries, taxing already over-burdened and understaffed health care systems. As the World Health Organization (WHO) reported at a 2002 joint meeting with the World Bank in Addis Ababa: There is an emerging crisis of health manpower in Africa. The situation threatens to defeat the efforts of African governments, private health care providers, NGOs, and donors for health improvement. Training programmes unsuited to changing health conditions, inadequate cooperation among the many parties concerned, and the losses of staff to opportunities outside Africa risk making Africa’s health care facilities barely able to function for lack of qualified, motivated doctors, nurses and other health workers. This situation is made even worse by the AIDS epidemic, which reduces further the availability of trained health workers by staff deaths and increases the demand for health care.1 To address the urgent need for more health workers, the President’s Emergency Plan for AIDS Relief (PEPFAR) calls for the placement of U.S. 1   WHO Report at Building Strategic Partnerships in Education and Health, a WHO/World Bank Meeting, Addis Ababa, January 2002, as reported by Ntiro, Simba, et al. in Information and Communication Technologies and Continuing Medical Education in East and Southern Africa, Report of a Conference held in Moshi Tanzania, 8–10 April 2003, Research Report 17, June 2003. http://www.ftpiicd.org/files/research/reports/report17.pdf.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS medical volunteers to complement and augment the capacity of local health workers in PEPFAR countries.2 The PEPFAR further identifies telemedicine as a tool to support these efforts.3 The experience of multiple organizations with experience in telemedicine, or more broadly defined, e-health, in low-resource countries has shown that while technology might be used to extend the presence of United States medical volunteers and build the capacity of local health professionals to combat HIV/AIDS, expectations about what they can achieve must be informed by a realistic understanding of the limited infrastructure and skills available to support them on the ground. Moreover, a commitment to using e-health should be driven by identified, real demands for improved access to information, data, training, etc., to combat HIV/AIDS and an understanding of how technology can meet those demands, rather than by a perception of e-health as an end unto itself. The most cost-effective and successful interventions are likely to be those that creatively leverage existing infrastructure and skills, such as low bandwidth e-mail, or those that introduce new technologies that are relatively inexpensive and easily adoptable, such as handheld computers and cellular telephones. A variety of e-health projects that follow these guidelines are already in existence and should be evaluated and considered as possible resource partners for a United States volunteer program before new projects are initiated. BACKGROUND: HEALTH SYSTEMS CAPACITY IN PEPFAR COUNTRIES Those countries hit hardest by HIV/AIDS face acute shortages of trained medical personnel. As Table E-1 indicates, the availability of physicians, nurses, and midwives per 100,000 people is limited in all 15 PEFAR countries. The availability of health care in these countries can be expanded in many ways, including: Recruiting and training new health workers (all cadres) from the local population. Expanding the capacity of the existing local workforce by, for example, upgrading skills or expanding health workers’ reach into underserved areas. 2   The President’s Emergency Plan for AIDS Relief, p. 37. 3   PEPFAR, p. 37.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE E-1 Nurses, Midwives, and Physicians per 100,000 Population 15 PEPFAR Focus Countries Nurses and Midwives per 100,000 Population Physicians per 100,000 Population Botswana 241.0785 28.7644 Côte d’Ivoire 46.2024 9 Ethiopia 20.5333 2.8581 Guyana 229 48.2 Haiti 10.7 25 Kenya 90.1 13.2 Mozambique 28.4303 2.4354 Namibia 284 29.5 Nigeria 118.5 26.916 Rwanda 21.0941 1.8737 South Africa 388.01 69.2095 Tanzania 36.6409 2.2659 Uganda 8.8 4.7 Viet Nam 74.752 53.4455 Zambia 113.1 6.9 SOURCE: World Health Organization, Global Atlas, last updated 26/Oct/04. Increasing the number of foreign national health professionals working in PEPFAR countries, including U.S. medical volunteers. Adding support for ancillary and administrative tasks to relieve health workers’ time for more patient care. Reorganizing health care delivery to realize more efficiency. These approaches are compatible with the PEPFAR’s strategy for “rapidly training and mobilizing health care personnel to provide treatment services.”4 To facilitate this effort, the PEPFAR explicitly states that “telemedicine and distance education can be used to build the skills of health professionals in the focus countries and strengthen local, national, and international connections among medical institutions.”5 WHAT IS E-HEALTH? A variety of technologies—and terms to describe their use—have been developed to facilitate the delivery of health care over long distances 4   PEPFAR, pp. 36–37. 5   PEPFAR, p. 37.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS throughout the world. “Telemedicine” implies the use of technology to support the delivery of clinical services, such as telesurgery or teleradiology. “Telehealth” is sometimes used synonymously, but often connotes the use of technology in health-related communication and information exchange, including distance training. “Information and communication technology (ICT) for health” can overlap with both of these concepts, but is also used to describe the use of technology to realize time and cost efficiencies and quality improvement in day-to-day practice, such as the use of handheld computers for routine data collection. The World Health Organization has adopted the use of the term “e-health” to encompass the whole range of technologies and applications that have variously been identified as telemedicine, telehealth, and ICT for health, and advocates their use to improve health care delivery in a variety of circumstances.6 Throughout this paper, the term “e-health” will refer broadly to the exchange of actionable information over distance to facilitate both health service delivery and capacity building within the health sector. The successful adoption of e-health in both low-resource and industrialized countries has enabled health professionals to overcome time and distance barriers and bring their expertise to poor and isolated communities that might otherwise be denied basic health services. Solutions need not be complicated or expensive to be effective. Even relatively simple technology such as e-mail can, for example, enable a United States health worker stationed in a capital city to communicate with local counterparts in rural villages about HIV/AIDS-related skin conditions, or enable peers separated by vast distances to communicate and consult. Simple e-mail-based discussion groups have proven to be an excellent forum for south-to-south support, knowledge building and sharing, and informal training within the global health community, as evidenced by SATELLIFE’s electronic discussion groups AFRO-NETS and E-Drug. The dissemination of medical literature via e-mail in electronic publications such as HealthNet News and HealthNet News AIDS is both cost-effective and responsive to real needs.7 E-health also opens up a wide range of training and continuing medical education opportunities. Several institutions have successfully implemented distance training and continuing medical education programs, enabling a 6   E-Health, Report by the Secretariat, WHO, December 2004. See also, A Health Telematics Policy in Support of WHO’s Health-for-All Strategy for Global Health Development, Report on the WHO Group Consultation on Health Telematics, 11–16 December, Geneva, 1997; WHO, 1998, available at http://whqlibdoc.who.int/hq/1998/WHO_DGO_98.1.pdf. 7   See the SATELLIFE website, http://www.healthnet.org.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Focus on South Africa: Cell Life More than 90 percent of South Africa is covered by cellular networks, and more than a third of all South Africans currently use cell phones. Cell-Life supports home-based care providers who collect medical and socio-economic data from patients through the use of applications on their cellular phones. Data are relayed over a GSM network to the central database. Medical and administrative staff access the data via a secure Internet connection for analysis. Communication and feedback are also provided to home-based care providers via SMS text messaging. SOURCE: http://www.cell-life2.os.org.za/home/home.html. small pool of educators to reach a wider audience than would otherwise be possible and to extend education and training into areas where it would otherwise be unavailable.8 A comprehensive and insightful analysis of the use of ICT to support continuing medical education emerged from a 2003 joint meeting sponsored the Centre for Educational Development in Health (CEDHA; Arusha, Tanzania), the Institute for International Communications Development (IICD; the Netherlands), and CORDAID (the Netherlands). The meeting report examines the constraints and opportunities for CME presented by ICT and outlines steps for moving forward in Uganda, Tanzania, Zambia, and Kenya.9 E-health has been practiced long enough for valuable lessons learned and best practices to have emerged. Some of the earliest e-health projects were sponsored by the International Telecommunications Union, which has since documented its lessons learned.10 Reproductive Health Outlook, the reproductive health website produced by Program for Appropriate Technology in Health (PATH), has produced a comprehensive analysis of the use of ICT for health in low-resource settings.11 The Telemedicine Information Exchange hosts a database of international and U.S.-based telemedicine 8   Kwankam, S. Yukap. October 2004. What e-Health can offer, Bulletin of the World Health Organization.82(10):800–801. 9   This report is available at http://www.ftpiicd.org/files/research/reports/report17.pdf. 10   This report is available at http://www2.telemed.no/publikasjoner/nedlastbare/telecomm_dev_bureau%20.doc. 11   This report is available at http://www.rho.org/html/ict.htm.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS projects and contains useful references about a wide range of related issues.12 THE TECHNOLOGY BEHIND E-HEALTH Pipeline Technologies An assessment of the potential to utilize e-health in any environment must first take into consideration the “pipeline” technologies that might be used. These are the networking mechanisms that convey information and data from one point to another. Their availability and cost vary considerably from country to country, and even within country, and so must be assessed on a case-by-case basis. Other factors that must be considered in assessing pipeline technologies include speed, capacity (bandwidth or volume), and cost. Access to these technologies varies along a continuum: in urban areas, high bandwidth access is usually available to medical and teaching institutions, while in rural areas, only radios or cellular telephones may be available. The availability of these technologies is determined primarily by national telecom policy and market forces, so organizations contemplating the introduction of e-health under time and financial constraints are well-advised to work within the range of the continuum available in their targeted environment. Table E-2 offers a list of the most widely used pipeline technologies in low-resource environments, as well as the types of hardware and software associated with using them. CONSTRAINTS TO USING E-HEALTH Limitations of Technology While all of the technologies described above are being used to varying degrees in low-resource countries, including those covered by PEPFAR, there are significant limitations that must be considered in planning e-health projects. Conditions that preclude the use of certain types of technologies in some environments include: Inadequate (sometimes nonexistent) telecommunication infrastructure and power supply to support networking beyond urban areas 12   See the Telemedicine Information Exchange web site, http://tie.telemed.org.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE E-2 Technologies and Related Tools Associated with E-Health in Low-Resource Environments Distribution/ Connectivity Local Networking Software Hardware Applicationsa Satellites DSL/Broadband Continuous data feed Continuous radio feed VSAT Dial-up Landline/Modem Cell (GSM modem) Radio (two-way) Radio (broadcast) LAN WAN–VSAT Wi-Fi Local Internet service “Sneaker” network (motorbike, bicycle, and feet) Satellite ground station Server/ Networking hardware (router, hub etc.) Computer workstations Laptop Handheld computer Cell phone Pager Smart card reader Scanner GPS Landline phone Digital camera Pencil and paper Basic office packages Accounting Database Communications Electronic medical record Reference texts aThe choice of appropriate software will be driven both by function and by the hardware available, yielding a range of options too broad to address in this paper. As the conceptualization of e-health projects to support United States medical volunteers under PEPFAR evolves and the number of variables is reduced, the range of appropriate software will become increasingly evident. Inadequate resources for institutions and facilities to acquire and sustain the ongoing use of technology Lack of local skills to use the technology, both among the technologists who need to support e-health systems and among the health professionals who will use them Any one or more of these factors can inhibit health workers’ access to the benefits of e-health. For example, a recent study done to determine the feasibility of expanding African universities’ access to scientific literature provided the following data on the cost—frequently prohibitive—of electronic access (see Table E-3). These conditions do not prelude the use of e-health, but they do dictate which types of technology are most appropriate in certain environments. The designers of e-health projects are well-advised to find creative technol-

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE E-3 Comparative Bandwidth Costs: United States, Uganda, and Nigeria Country Institution Current bandwidth (downlink/uplink) Cost/month Cost per kbps per month United States n/a 1.5 Mbps US$399 $0.266 Uganda Makerere University 1500 Kbps/ 786 kbps US$22,500 $9.84 Nigeria Obafemi Awolowo University 512 Kbps/ 128 kbps US$12,800 $20.00 SOURCE: IDRC. Open and Closed Skies: Satellite Access in Africa, the International Development Research Centre (IDRC), Canada, 2004. This report is available at http://web.idrc.ca/en/ev-51227-201-1-DO_TOPIC.html. ogy solutions within these constraints rather than to invest the time and resources that would be required to change the technology environment. Experience has shown that when the introduction of technology is compatible with existing infrastructure and skills, it is possible to achieve sustainable, cost-effective results. Limitations of Current Practice Current practice, clinical and administrative, may not be easily adaptable to e-health. E-health is a tool to complement health care services; it cannot correct weaknesses or problems within health care systems or function well in environments characterized by: Poor data-management practices or health information systems (HIS) Obstructionist politics around information “ownership” Lack of leadership or vision Other political, systemic, or institutional barriers, such as staff resistance to technology Limitations of the Existing Workforce The use of e-health to extend the United States workforce presence will require the cooperation of and coordination with the existing local workforce, which, as has been discussed, is already overburdened by enormous

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Focus on Haiti: Partners in Health, Zanmi Lasante Health workers at Zanmi Lasante in Cange, Haiti consult with counterparts at Partners in Health in Boston, Massachusetts using desktop computers and a satellite connection to share web-based records for clinical management. The system allows patient consultation and care decisions to be made remotely. SOURCE: www.pih.org. caseloads, reporting requirements, training and supervision, etc. E-health interventions must be perceived as collaborative and constructive, resulting in visible benefits rather than increasing the workload, if they are to receive the local support they need to succeed. E-Health in Action: The Uganda Health Information Network Experience has shown that projects that recognize and work within these constraints can be very successful. Working in partnership with Uganda Chartered HealthNet (UCH), SATELLIFE has created the Uganda Health Information Network (UHIN) to support health data and information exchange. The network combines the use of handheld computers (also known as personal digital assistants or PDAs), the local GSM cellular telephone network, and self-contained relay stations or “Jacks,” to provide a two-way flow of data and information between health facilities in Mbale and Rakai Districts and the Ministry of Health in Kampala. Now moving into its second year of operation, UHIN is independently owned and man- Focus on South Africa: Africa Centre for Health and Populations Studies An “HIV Confidant” carries confidential HIV test results to remote locations on handheld computers (PDAs) customized by the Africa Centre. The device features confidential double-key entry for both provider and patient, records patient consent, and tracks requests for results. SOURCE: http://www.africacentre.org.za

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS aged by UCH, an independent NGO based at Makerere University Faculty of Medicine. Two routine data collection forms have been converted to the PDA format, enabling health facilities in the target districts to submit their monthly data reports to the Ministry of Health via the network. A cost-effectiveness study has shown that UHIN results in a 25 percent cost savings in this routine data collection, a figure that the project partners expect to increase as additional data collection forms are converted to the PDA. The network has resulted in significant local capacity building, both at UCH, which has acquired the technical and administrative skills to manage the network, and at the networked facilities in Mbale and Rakai, which are not only improving their data collection capacity but also receiving valuable content through the network.13 E-HEALTH AND HIV/AIDS Understanding the Environment, Identifying Real Demands The design of e-health programs to expand the United States workforce and build local capacity in PEPFAR countries must complement the existing in-country networks of HIV/AIDS care providers. Decentralization has resulted in an expansion of the network of health workers engaged in HIV/ AIDS, ranging from highly trained, hospital-based medical staff in urban settings to community volunteers in rural villages. A U.S. volunteer can theoretically be located anywhere and/or communicate with anyone within the network of hospitals, clinics, research and academic institutions, hospices, voluntary counseling and treatment (VCT) centers, orphan and vulnerable children (OVC)-focused organizations, counseling and support groups, home-based care, education and training programs, and work-based centers. UNAIDS has suggested that ICT can be effective in supporting this network all the way down to the community level,14 but several questions must be answered, such as: Where will volunteers be placed? With whom will they communicate? About what? And why? Answering these questions may prove far more complicated than might be expected, as illustrated by an examination of record keeping needs related to anti-retroviral drugs (ARV), an area in which e-health would seem to be a natural solution. The widespread use of ARV in developing coun- 13   See the UHIN website at http://www.pda.healthnet.org. 14   Potential for ICT to Support Community Health Crganizations, 2004 UNAIDS Report on the Global AIDS Epidemic, Section 2. This report is available at http://www.unaids.org/bangkok2004/GAR2004_html/GAR2004_00_en.htm.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS tries requires record keeping at both the patient and facility level, yet the practice and quality of record keeping varies widely between and within countries. Medical records are not standardized within or across PEPFAR countries. Local health clinics may not keep patient records and instead may rely on the care provider and the patients to remember the illness and treatments previously prescribed. In some cases patients carry a “record” with them that includes dates of visits and health workers’ hand written notes. Each time patients visit a health provider, they must bring the record with them. Few, if any, rural clinics maintain electronic records for either patient care or clinic utilization. Rather, information is recorded as a tick mark in a ledger. The entries are counted at the end of the month and copied over onto paper reporting forms that are collected or sent on to the next higher level of care to be aggregated into regional and national level reports. Another important consideration is that each clinic must fill out multiple, often duplicative reports, the number and nature of which is determined by the number of vertically funded programs (and donors) they are drawing resources from. These reporting requirements, while perhaps important for a range of needs, nevertheless diminish the amount time a care provider has for direct patient care. Multiple discussions are underway in an attempt to agree upon a uniform data set across all ARV programs, but many organizations have developed their own EMR or database, reflecting a desire to continue using their own product. At the same time several projects are underway to introduce clinic level patient record keeping using computers, handheld computers and smart cards. These activities, sometimes complementary, sometimes mutually exclusive, illustrate that while the tools of e-health can be used to meet the record keeping and data collection demands generated by the widespread use of ARV, they can only be maximally effective only if the underlying organizational, logistical, and political issues are addressed, and efforts are coordinated at multiple levels.15 Targeted Content, Appropriate Technology Understanding the environment in which volunteers will be placed, both to maximize the impact of their presence in country and to facilitate 15   Though it is beyond the scope of this paper to explore issues regarding volunteer selection and placement in detail, this illustration also suggests that the range of expertise required is not limited to physicians and nurses, but may also include nonclinical expertise in systems management, information technology, records, pharmaceuticals, palliative care, work flow management, etc.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Focus on Rwanda: Central Hospital, Kigali—Institute of Tropical Medicine, Antwerp An on-site training course on the use of ARV is conducted at the Central Hospital by ITM staff, then followed up by remote e-mail support, continuing training, and access to a community of practice that reinforces the theoretical course. SOURCE: http://telemedicine.itg.be/telemedicine/site/Default.asp?WPID=59. their ability to build local work force capacity, makes it possible then to consider how e-health can facilitate their work, and the content they will need to exchange with their local counterparts. Virtually any two points within the network of HIV/AIDS caregivers can be linked, and the content they exchange can range from simple e-mail messages and data files to full-color images and streaming video, but not all solutions are viable or cost-effective. Key issues to consider in selecting which technology is the most appropriate include: How often will they need to be in touch? How critical is it that they have access to each other on demand? What volume of information will they be exchanging? Will it be a one-way flow or a two-way flow? How many other people may need to see the information? Will they be exchanging confidential information? The answers to these questions, paired with an understanding of the IT environment, make it possible to design appropriate e-health programs. The range of options is illustrated in Table E-4. Personal Digital Assistants (PDAs) and HIV/AIDS SATELLIFE has found that PDAs lend themselves especially well to information dissemination and data collection and analysis. Together with the WHO, SATELLIFE is testing the use of PDAs to keep facility-level patient ARV care records (an “ARV patient card”), tracking cohorts of patients on ARV and their status. SATELLIFE’s longer-term goal is to develop an “HIV/AIDS PDA” that combines many of the PDA applications that SATELLIFE has already successfully tested, but is specifically targeted toward the needs of HIV/AIDS caregivers. Its functions would include the following. Patient screening and rapid assessment. For example, a local nurse can interview patients using an interactive PDA form, receive a recommendation, and triage patients for a physician.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS TABLE E-4 E-Health Options Networking Technologies Available E-Health Applications Possible Broadband Internet (via satellite, telephone) Web-based information sharing, live teleconferencing Low bandwidth e-mail Consulting, program coordination, routine communication, text only journals, discussion groups, and other references Cell phone Consulting, program coordination, routine communication, patient reminders, simple data reporting Multiple technologies (including handhelds, smart phones) Patient record exchange, training and CME, reporting, supervisory support, inventory management, secondary diagnosis, text and reference material, e-books, data collection and reporting, databases, voice recording, digital photos, etc. Preliminary diagnosis. For example, a nurse can use an interactive PDA form to determine whether a patient should be tested for HIV/AIDS, without that person needing to see a physician. ARV management. For example, a community health volunteer can use a PDA to keep track of ARV regimens to support compliance during household visits. Patient records, patient tracking. For example, each patient can be issued a smart card containing his or her personal record which can be updated on the PDA at each visit. In the case of orphans, vital documents, identification, photos, etc., could also be recorded to facilitate care-giving and preserve vital records in the absence of family support mechanisms. Data collection, including demographic surveys. Virtually any data that is routinely collected using pencil and paper can be translated into an electronic form. (Open-ended questions are less adaptable to this format.) Information dissemination and knowledge building. PDAs can hold a virtual library of resources, including treatment guidelines, medical references and text books, etc. COST EFFECTIVENESS OF E-HEALTH Documented evidence regarding the cost effectiveness of e-health interventions overall, including in industrialized countries, is limited, although

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS this reflects a lack of study, rather than a lack of cost-savings.16 However, there is some evidence that low-bandwidth technology can be especially cost effective in resource poor countries.17 The cost effectiveness study by SATELLIFE and Uganda Chartered HealthNet is one of the few rigorous studies available on the cost effectiveness of handheld computers, indicating a 25 percent savings in the cost of data collection as opposed to paper and pencil methods.18 Other partners with whom SATELLIFE has worked to establish PDA capacity, including the American Red Cross, the Uganda Red Cross, and Management Sciences for Health, have not conducted comprehensive studies, but have reported significant cost savings to SATELLIFE based on standard project evaluations.19 The long-term sustainability of a project must factor into considerations of cost effectiveness. Short-term analysis may reflect savings that can quickly be lost if the host institution is encumbered with an unsustainable program once donor funding is exhausted. Therefore, the design of e-health programs must account for the ongoing costs of training, hardware and software maintenance, connectivity (Internet, telephone), and other recurring expenses. E-HEALTH, HIV/AIDS, AND VOLUNTEERS E-health can factor into the design of a program for United States medical volunteers working in or with PEPFAR countries in a variety of ways. The extent and nature of an e-health component in the volunteer program will depend on how the program itself is ultimately designed, but several models should be considered: 16   Systematic review of cost effectiveness studies of telemedicine interventions. BMJ 2002; 324:1434-1437, available at http://bmj.bmjjournals.com/cgi/content/full/324/7351/1434; Kwankam, S. Yunkap, Bulletin of the WHO, pp. 800–801. 17   Frasier and McGrath, Information technology and telemedicine in sub-Saharan Africa. BMJ. 2000. 321(7259):465-466, available at http://bmj.bmjjournals.com/cgi/content/full/321/7259/465). 18   This study is available at http://www.healthnet.org/coststudy.php. 19   Presentations on two of these projects were made at Handheld Computers in Africa: Exploring the Promise for the Health Sector, a conference sponsored by SATELLIFE, Uganda Chartered HealthNet and IDRC, May 12–13, 2004, Entebbe, Uganda. For more information on the Uganda Red Cross project, see http://pda.healthnet.org/docs/fredrick_urcs_presentation.ppt. For more information on the MSH project, see http://pda.healthnet.org/docs/arin_conf_presentation.pp.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Focus on Uganda: Satellife, Uganda Chartered HealthNet, Makerere University The Uganda Health Information Network enables health workers in Mbale and Rakai districts to use handheld computers (PDAs) to collect data, receive training and reference materials, and send and receive e-mail. Users connect to the network using the infrared beam of their PDAs to connect or “hot sync” with an access device which in turn communicates with a central server in Kampala via the GSM cellular network. The network facilitates both routine data collection and reporting between rural health facilities and the District Health Offices and continuing medical education. SOURCE: http://www.pda.healthnet.org. E-Health to Support Volunteers A variety of volunteer placement programs are already utilizing tools associated with e-health to support overseas assignments, and can serve as models for the proposed PEPFAR volunteer initiative. For example, St. George’s Hospital in London uses an e-mail health consultation service for overseas volunteers, who use the system to address diverse medical concerns and receive collegial support.20 Programs such as the Peace Corps are also likely to have useful models that could be adapted. E-Health to Extend the Reach of Volunteers into Remote Areas Several models exist in which e-health is used to extend the reach of specialized services into rural areas or to build local capacity. For example, Dr. Roy Colven of the University of Washington, working in partnership with the MRC Telemedicine Research Council, has established a teledermatology project at the University of Cape Town in South Africa. The network will serve regions of southern Africa that have limited access to health care providers. Using e-mail and digital cameras, remote practitioners send photographs of HIV/AIDS-related skin disorders to consulting physicians working in Cape Town, who review the digital images for consultation and diagnosis.21 20   E-mail consultations in international health. Lancet 2000; 356(9224):138. 21   For more information on this project, see http://archives.thedaily.washington.edu/search.lasso?-database=DailyWebSQL&-table=Articles&-response=searchpage.lasso&keyField=__Record_ID__&-keyValue=9983&-search).

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Also in South Africa, the Tsilitwa telehealth project enables nurses to use a web camera to send live pictures of a patient over a wireless network to a doctor at the University of Cape Town. Simultaneously, they can consult live via telephone about the patient. Tsilitwa is an extremely poor and remote village that is difficult to reach by public transportation and has virtually no other means of communication beyond this network.22 E-Health to Provide Remote Support and to Facilitate Institutional Relationships One model for the effective engagement of volunteers may include an on-site visit and “rotation” by a senior level health provider (defined as a care provider at a peer level who has had significant HIV/AIDS care and treatment or patient management experience in their own practice) who is able to establish a trusting peer relationship with a provider or care site in a PEPFAR country and makes a commitment to maintain a relationship with that provider or clinic. This relationship can continue after the volunteer returns home through “e-twinning,” the use of e-health tools to provide: Sustained communication and consultations Access to reference and resource materials not available in the PEPFAR country Regular updates of relevant medical and clinical information A peer network (e.g., e-mail discussion groups) that enables the volunteer and the PEPFAR country program to call upon the resources of a community of practice Building on Existing Programs As an e-health component of the United States volunteer program is developed, it will be important to assess and, where possible, leverage existing programs. Formal e-health strategies have been adopted by several PEPFAR countries, both at the national and institutional level. Examples include: The Zambian Ministry of Health has been actively working to 22   The South African NGO Bridges.org has prepared a case study on this project, available at http://www.bridges.org/iicd_casestudies/tsilitwa_telehealth/.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Focus on Mozambique : Empresa Nacional de Telecomunicações de Moçambique (TDM), Maputo and Beira Central Hospitals, WDS Technologies of Switzerland Medical personnel at central hospitals in Maputo and Beira engage in teleconsultation and teleradiology using a terrestrial and satellite links to exchange histories, images, and test results. SOURCE: http://www2.telemed.no/publikasjoner/nedlastbare/telecomm_dev_bureau%20.doc. develop a national telehealth strategy as a means of extending health services throughout the country.23 In Tanzania, the Muhimbili University Health Exchange Forum has been established “to facilitate communication and the flow of health information between healthworkers in the districts and regions of Tanzania and health experts and postgraduate students of Muhimbili.”24 In Uganda, the Academic Alliance for AIDS Care and Prevention in Africa has identified telemedicine as one of the tools it will use to support the training efforts at the Infectious Disease Institute in Kampala.25 South Africa has a national telehealth strategy that includes hospitals and universities, with the goal “to make telemedicine live up to its potential as a valuable tool to improve access to high quality and cost effective health care services in South Africa.”26 Existing federally-funded programs such as the Global HIV/AIDS Program, Office for the Advancement of Telehealth, at the U.S. Department of Health and Human Services, should also be explored for possible linkages, models, and lessons learned.27 23   Chanda, Kenneth, Outline of telehealth development in Zambia, 1 September 2004, http://209.250.143.167/atp/_disc1/00000018.htm. 24   The Muhimbili Health Exchange Forum website is http://www.muhef.or.tz/. 25   The website on the training program of the Academic Alliance for AIDS Care and Prevention in Africa is http://www.aaacp.org/training.index.html. 26   This report is available at http://www.kznhealth.gov.za/telemedicine1.pdf. 27   The website for the HRSA Global HIV/AIDS Program is http://hab.hrsa.gov/special/global.htm.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS KEY CONSIDERATIONS Over the course of its 16 years in implementing e-health projects throughout Africa, Asia, and Latin America, SATELLIFE has learned that a variety of considerations beyond content and technology must factor into the design of a successful program. These lessons include the following. Technology is disruptive. E-health programs have the potential to upset existing hierarchies and work patterns and procedures, creating both political and administrative conflicts. Change management must be deliberate and cautious. Information ownership is a politically charged issue. Control of information and data is heavily tied to power relationships at many levels. E-health programs must be sensitive to the politics and relationships in place from the Ministry of Health to the front-line community volunteer. Technology is a tool, not a solution. E-health in and of itself cannot fix health systems, nor is it a substitute for good practices. Existing practices must be understood and factored into the design of e-health programs. Back-up, security, and privacy issues should be considered early in the design process. Systems must be designed with redundancy and security, and protocols must be established to maintain them from the outset. The level of privacy and confidentiality required for information and data exchange must be understood before the technology and software are selected. They must be built into the system. Explore alternative power sources (battery, solar, generator). Creative solutions for supplying power may extend the reach of some technologies into rural areas. E-health programs should not create additional burdens for health workers if the technology is to be adopted successfully. E-health programs must be seen as part of the solution, not part of the problem, and must be inclusive and collaborative. A local champion can ensure the success of a project. It is imperative to find local advocates who know the system, are invested in e-health, and are invested to influence key stakeholders. Training of end users and technologists must be thorough, and ongoing support must be available until the technology is fully adopted. Training of trainers is essential to ensure that second-generation users will be successful. The long-term sustainability of the project must be considered from the beginning—not when funding is winding down—so that local partners are not encumbered with unmanageable recurring expenses. Many local models of successful e-health programs already exist.

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Healers Abroad: Americans Responding to the Human Resource Crisis in HIV/AIDS Partnering with these programs can be far more cost-effective and responsive to local needs than launching new projects. CONCLUSION E-health has proven to be a cost-effective mechanism for enabling health workers to overcome barriers of time and distance and to exchange actionable information and data relating to health service delivery in multiple settings in low-resource environments. Successful projects are demand-driven and remain responsive to both local content needs and existing practices. They are also grounded within the range of the technology “continuum” that is realistically available to them, creatively adopting applications that are compatible with the local telecommunications infrastructure. Within the context of a United States medical volunteer program, e-health has the potential to provide support to volunteers, to extend the reach of volunteers into remote areas, and to serve as a conduit for capacity building and support between volunteers and local counterparts. Sufficient functional models exist to merit a more comprehensive inventory of e-health activities in each PEPFAR country to determine whether the placement of volunteers may be able to leverage existing initiatives, although such a determination should be made within the perspective of other urgent critical needs.