The taxonomy for the type of technology used (Box 1) was developed by coding all programmes on the basis of: (i) the device used (e.g. phone, camera) and (ii) the use case (e.g. videoconference, short messaging service [SMS]). Use case is the way in which the device is applied. Individual devices can link to multiple use cases (e.g. a phone can be used for voice and/or text messaging).
The data revealed that technology programmes rely mainly on phones and computers (71% and 39% of programmes, respectively, as shown in Table 1), and frequently on both. In particular, 63% of the programmes using phones rely exclusively on cell phones for their operations.
Closely tied to the device is the primary use case (Fig. 5). Voice is the most frequent use case for technology devices. Just over 34% of programmes use voice; almost 32% use applications or other software, and approximately 31% use some form of text messaging (SMS).
Fig. 5. Technology-enabled programmes, by use case employed
Purpose behind use of the technology
The taxonomy for the purpose behind the use of technology by health programmes (Box 2) was developed through a review of the goals of each technology innovation. Six broad reasons surfaced, the most common one (42% of programmes) being to extend geographic access to health (Fig. 6). Examples range from TeleDoctor in Pakistan, which provides access to physicians through a telephone hotline,19 to E Health Point in India, which facilitates patient–doctor interactions in rural areas through videoconferencing.20The second most common purpose (38% of programmes) behind the use of technology is to improve data management. Within this category, 38% of programmes focus on data collection, 35% on data organization and analysis and 27% on both. For example, Nacer21 uses telephone and internet technology to allow health workers in Peru to collect data on various populations and share it remotely with medical experts for data analysis. Facilitating patient communications outside regular health visits and improving diagnosis and treatment are the purposes behind technology use in 31% and 17% of the programmes, respectively. In addition, a few programmes use technology to mitigate fraud and abuse and to streamline financial transactions.
Fig. 6. Technology-enabled programmes, by purpose of use of technology
The use of technology by a large percentage of programmes to extend geographic access to health care is particularly promising given the critical shortage of health workers and poor distribution of service providers in many low- and middle-income countries.These programmes often take the form of telemedicine, which connects physicians and patients via technologies such as video chat, or health hotlines, which provide patients with around the clock access to qualified doctors. Interestingly, 70% of the programmes focused on improving diagnosis and treatment also use technology to extend access. These two purposes go hand–in–hand, especially when a programme aims to enable workers with less training to provide high–quality care by using clinical decision–support software to improve the quality and consistency of practice. For example, M–DOK was a pilot mobile health system that allowed rural community health workers in the Philippines to send patient information over text message to specialists in urban areas, who then advised on accurate diagnosis and appropriate treatment.
Although mitigating fraud and abuse and streamlining financial transactions are the least common of the identified purposes for technology–use, this may be a major area of opportunity for e–health in the future. Low– and middle–income countries are seeking new solutions to improve oversight and accountability in health transactions. They can reduce the loss of scarce health care resources by monitoring drug purchases and verifying receipt of services before insurance payments are transferred. Mobile payment technologies, such as M–Pesa in East Africa, have become increasingly popular and in all likelihood will continue to be used for streamlining financial transactions in health.
Devices and use case
Anecdotally, many policy–makers and funders seem to be particularly excited about the potential of newer, emergent technologies, such as tablets. Nevertheless, the expansion of mobile infrastructure and the concurrent increase in the use of telecommunication devices among the poor has allowed programmes to utilize existing devices and invest less in new technologies. This study shows that common technologies such as basic cell phones and computers are frequently used.
Interestingly, text messages fall third in the distribution of technology use cases, with voice and software/applications ranking higher, despite the global excitement over SMS.26,27 Programme implementers have cited greater accessibility for illiterate populations as one of the advantages of voice messages over text messages.
Certain purposes are logically more closely associated with specific devices. This study found that 94% of programmes that facilitate patient communications outside traditional health visits use phones, while only 28% use computers. This is not surprising, since patients in low–income settings are more likely to own phones.
Primary care staff require strong diagnostic skills, while secondary care providers need specialized knowledge about particular diseases and conditions. According to this study, programmes focused on primary and secondary care use technology primarily to extend geographic access to care (57% of general primary care and 75% of general secondary care programmes) and to improve treatment and diagnosis (26% and 67%, respectively). In this way, these programmes are able either to connect underserved patients with specialized and trained physicians or to improve the skills of lesser–trained health workers who are more accessible to the patients.
On the other hand, 43% of HIV/AIDS, 35% of tuberculosis and 33% of family planning and reproductive health programmes that are technology–enabled use technology to facilitate patient communications, which is thus one of their most important aims. This is probably because they require frequent low–level provider–patient interactions to ensure compliance with treatment protocols and impart general education
Broadly assessing the impact of ICT programmes on indicators such as service access, quality, cost and efficiency was beyond the scope of this study for lack of the necessary data. However, 16 of the 176 technology–enabled programmes responded to a request for self–reported clear and quantifiable impacts, from improvements in the quality of care to decreased costs. Six programmes described an increase in user satisfaction, the most common impact reported. For example, 92% of the patients using GlicOnLine, which helps diabetics in Brazil calculate insulin dosages and plan their diet, reported that the system had improved their lifestyle.User satisfaction is a key impact, since acceptance by end users, whether patients or health workers, is a big concern for many e–health implementers. Five programmes reported improvements in the quality of care, often relating to increased patient adherence to the physician’s recommendations or to drug regimens. Operation ASHA reports that its system, which uses fingerprint scanners to verify adherence to tuberculosis medication in slums in India, has decreased the fraction of patients who fail to complete treatment from 60% to less than 3%.29 Four programmes report an impact on efficiency, often in the form of time saved. The e–health community may see an increase in reports of efficiency impacts because it is natural for technology to have such an effect, particularly on account of ICT’s ability to transfer data almost instantaneously. For example, the RapidSMS system in Malawi, which collects data on paediatric patients using mobile phones, has reduced transfer times for some data from 1 to 3 months to only 2 minutes.Similarly, decreased costs resulting from technology are reported by few programmes at present,but such reports could rise,especially as savings from increased efficiencies overcome initial capital costs. This small number of self–reported, quantifiable positive results suggests that e–health can have an impact, although more rigorous evaluation is needed.
Barriers to implementation
As programmes look for opportunities to scale up e–health services, they may be hampered by persistent reliance on donor funding (Fig. 4), which highlights the need for an eventual transition to alternative and diversified revenue sources (e.g. government contracts, insurance or direct payments from consumers) to bring effective programmes to scale. In addition, it appears to be more difficult to adapt an existing organization to a given technology than to build an organization with technology from scratch. Fig. 3 suggests that programmes launched before the advent of ICT are not rapidly adopting the new technologies. When this study was conducted, 73% of programmes in CHMI’s database were not technology–enabled, and interviews with a selection of implementers suggest that organizations face important barriers to implementation. Implementers have pointed out problems with end–user acceptance of the technology attributable to factors such as the user’s lack of familiarity with the technology, a lack of cultural appropriateness or a lack of incentive to adopt new tools. Another key concern is the lack of the necessary infrastructure to provide reliable electricity and internet access. One implementer cited this as a key reason for moving from computers to mobile phones, for which the necessary infrastructure is more readily available. Costs, both initial and ongoing, also surfaced as a key impediment to technology implementation. Such considerations may determine if, when, and how a technology is incorporated into a programme.
ICT is being deployed around the world in many areas of health. Six major reasons for the use of ICT in health have emerged in this paper. Some, such as extending access to care or improving data management, are rather common, but there are budding uses as well, specifically in fields such as mitigating fraud and abuse and streamlining financial transactions. These fields deserve special attention to ensure their proper development. As e–health continues to evolve, many of the current challenges faced by health systems in low– and middle–income countries, such as the shortage of health workers in rural areas, the variable quality of care, lack of patient compliance, and fraud, will potentially be mitigated through the wide deployment of ICT. It will be crucial to continue to track which of these purposes are being successfully fulfilled by technology and what devices and use cases are most effective in attaining them. This will require more systematic evaluations and better codification of lessons learnt from existing programmes, which in turn will allow programmes that are currently struggling to employ technology to make educated decisions about when and how to implement ICT.