The Intersection Of Health

Published Date: 02 Nov 2017

m Health and e Health- a guide to recent initiatives in Bangladesh.

ABSTRACT

Tanvir Ahmed, Azfar Sadun Khan, Rubana Islam, Adnan Ansar, Mohammad Iqbal, Henry Lucus and Abbas Bhuiya

Keywords: e- and m-Health in Bangladesh, electronic health and Bangladesh, mobile health and Bangladesh

Globally e Health and m Health are considered tools for information management system and service delivery. Like high income countries, LMICs are also currently in the process of designing and implementing interventions with such technology platforms. This paper takes on a practical approach to explore scopes and challenges for e and m-Health for Bangladesh particularly stressed due intense resource constraint and discrepancy between technology development and deployment. In seeking to integrate e Health with the current health system in Bangladesh, the challenge was to address issues, not only how they can be implemented, administered, financed and staffed, but also regarding the nature of services to be provided. A screening matrix using Arksey & O’Malley framework, complemented by SWOT analysis was utilized to outline common traits among twenty e or m Health interventions revealed so far in the country. Major findings suggest lack of effective communication among stakeholders, lack of assessment of patient’s privacy and more importantly lack of research evidence on the success & sustainability of major initiatives. There is a strong demand for appropriate capacity building and experience sharing on e and m Health related awareness, sustainability and knowledge of how to establish and retain such initiatives especially at the policy making and implementation level. The study concludes that with all the potential of electronic and mobile Health, Bangladesh needs much preparation and planning to initiate and scale up e and m Health initiatives. One of the ways forward in this context can be creating more space for formative and operational research in this regard.

Introduction

Bangladesh is still haunted by problems with accessibility to and affordability of quality health services. This has put the country’s current momentum toward universal health coverage (UHC) in jeopardy. The existing health system is largely dependent on out-of-pocket payments, which constitute 60% of health care spending[1]. In addition, high population density is resulting in new and unfamiliar public health challenges[2]. Despite impressive gain in numerous health indicators, recent research have raised serious questions relating to issues including heath service utilization quality and equity. These issues are central to the establishment of an effective health system in any country. This becomes even more crucial when a new system replaces or integrates with an existing one.

Electronic health (eHealth) has gradually become an increasingly popular model of health service delivery in many countries since the 90s [3]. Bangladesh is no exception. A number of electronic tools have been employed, including the recent addition of mobile phones and associated technologies[4]. The assumption has been that these tools in combination can better equip health care providers, enhance the quality of care and reduce the existing disparities in health[4]. However, at least in Bangladesh there is insufficient evidence of the effectiveness of eHealth in terms of improving access to and/or affordability of promotional, preventative, curative, or rehabilitative services[5]. In seeking to integrate eHealth with the current health system in Bangladesh, the challenge is therefore to address issues regarding the nature of services that will be provided, not only how they can be implemented, administered, financed and staffed, the focus of much of the literature in this area[6-8].

Bangladesh is currently in the process of adopting a framework for eHealth , based on a decade of experience[9, 10]. In developing this framework it will be of the utmost importance to explore the actual and potential contribution of existing eHealth initiatives and the contexts within which they have been implemented. The purpose of this paper is to produce an inventory of such initiatives, identify the most effective and discuss the challenges for its integration into the health system.

Methods

This study was conducted over the period January to March 2012. Partly because of the inevitable time-lags in publications which are a serious problem in such a rapidly developing area, there are only a very limited number of peer reviewed journal articles relating to current mHealth and eHealth interventions in Bangladesh. It was decided therefore to conduct a scoping study, adopting a flexible strategy that could consider both peer reviewed and other evidences. However it is appreciated that such studies require careful design to avoid concerns as to their robustness[11]. The present study therefore adopted a methodological framework derived from that developed by raising questions around its robustness. Hence the present study adopted the methodological framework developed by Arksey and O’Malley[12],making variations only where pertinent;

Arksey and O’Malley consider scoping studies only in terms their application to a literature review but for the purposes of this study a short descriptive survey, gathering information on selected interventions in discussions with the key informants was seen as a necessary addition. The study framework involves six interrelated steps. Figure 1 shows the overall study design and the tools adopted at each step.

-Identifying the research question along with the articulation of specific objectives allowed the development of an effective search strategy for the desk review. This identified, revealed documents (mostly web-based) related to eHealth and mHealth initiatives in Bangladesh. Using eHealth and mHealth in Bangladesh, electronic health Bangladesh, mobile health Bangladesh etc. as keywords extensive web search was conducted using Google & Google Scholar.  Personal communication and informal discussions supplemented this list. Narrative review of the information collected then assisted in the formulation of a screening matrix (serving as data charting form, step 4 of the Arksey & O’Malley framework [12]) to outline common traits among these initiatives (See Annex, Table 1).

One of the study objectives was to assess the effectiveness of selected eHealth and mHealth interventions. For this purpose a semi-structured tool was constructed using the above screening matrix to conduct a preliminary exploratory analysis of these interventions. As described in the framework, a descriptive statistical summary (see findings section) and a thematic analysis was undertaken. The latter was guided using a case study approach. Data from the screening matrix and additional discussion with key informants were used to prepare each eHealth and mHealth initiative as a case study. To describe and interpret the potential of each initiative as a case study, a SWOT (Strength, Weaknesses, Opportunities and Threat) analysis[13] was implemented using themes from the WHO’s recommended building blocks[14]. To improve methodological rigor, a final round of consultation (optional in the framework) was incorporated into the study. Representatives from the identified eHealth and mHealth initiatives were invited to review the findings. Any disagreements were explored until a consensus was reached as to the appropriate data to be considered in analysis. The step by step procedure aided with triangulation of findings for authenticity.

Accessing information was very challenging. With few exceptions, private sector actors were unwilling to share their data. Data on public sector interventions were generally accessible through formal and informal channels. NGOs were the most forthcoming and proved enthusiastic participants in the study. Where data was not available, information was obtained from published sources, primarily reports and webpages. Table 1 includes the themes used for data compilation and analysis.

Table 1. Themes used for the analysis

Themes

Categories/Description

Organization profile

Managed by

Govt., Private, NGO

Entity

For profit (commercial/non-commercial), not for profit

Priority

Health over telecom, telecom over health

Donors & Partners

Banks, Research organizations, Media, Telecom etc.

Program overview

Project Status

Planned, ongoing, completed,

Main Component

eHealth/ mHealth

Medium

SMS/voice call/computer/other

Technological platform

Software, Hardware

Target Population

e.g. rural villagers, age groups etc.

Measure of utilization

# of people registered, # of people using services

Financial Profile

Startup Cost, Operational Cost, Total Revenue

Human Resource profile

Type and number of staff and training

Service Profile

Disease Management

Disease covered, mode of provision, provider, cost

Health Awareness

Topics covered, mode of provision, provider type, cost

Diagnostic/Imaging

Tests covered, mode of provision, provider, cost

MNE Framework

Indicators

input/process/output/outcome/impact

Project Evaluation (if done)

Main Findings

Uptake of findings

Sustainability Plan

Strategy

Any plans created for Present undertakings, upcoming deals or work in progress arriving shortly, that drives the institution forward in the defined sector

Capacity

Resources and infrastructure support required/available to sustain the strategy and future direction in the defined sector

Future Direction

Major challenges

If no sustainability plan is evident, try to find out what were the major challenges that hampered sustainability

Findings

eHealth and mHealth initiatives in Bangladesh: Electronic and mobile health services in Bangladesh surfaced in late 90’s. Twenty such initiatives were identified in this study. Twelve are managed by for profit private entities, four by public bodies, and two each by NGOs and private social enterprises (figure 2). The projects vary from pilot stage to fully operational Seventeen are ongoing though a few of these will end in the near future. While some are more than 5 years old and one has been fully operational for over ten years, most are more recent and three have been initiated. Nine have recently completed a pilot stage, and are currently continuing with that model, while in full scale operation. Annex 1 provides a full list of the initiatives identified.

The earliest intervention was a telemedicine initiative established in 1998 by a charitable trust, Swinfen Charitable. It established a link between the Centre for the Rehabilitation of the Paralyzed (CRP) in Bangladesh and the Royal Navy Hospital Haslar, in Gosport, UK. During the same year, the Government of Bangladesh (GoB) undertook its first ehealth initiative via the Ministry of Health & Family Welfare (MOHFW)[15]. The use of mobile phones to support service delivery initiated by a private company, Telemedicine Reference Center Limited (TRCL). TRCL, linked with GrameenPhone to pave the way for mobile based health services to be provided by private telecom companies in Bangladesh.

The success of this collaboration was a probable factor in the formation of additional professional coalitions of this nature; Bangladesh Telemedicine Association (BTA) is a non-commercial eHealth & mHealth body that formed in 2001.

BTA promotes awareness primarily among doctors and the Sustainable Development Network Program (SDNP) founded in 2003, aims to establish better collaboration and understanding between providers. A number of NGOs, including BRAC, Sajida Foundation and DNet subsequently developed an interest in this area, mainly focusing on enhancing the efficiency of project implementation, for example in terms of monitoring and evaluation of mHealth interventions.

There are incidences of failed interventions which were never documented, of which our findings identified two: the joint telemedicine service between the Bangladesh University of Engineering and Technology and, Comfort Nursing Home (2003) and the Bangladesh DNS Diagnosis Centre (2004). The reason for these failures was reported as lack of financial viability.

To better understand the present eHealth and mHealth in Bangladesh, a SWOT analysis was performed, based on the WHO framework for the building blocks of health systems[14]. The findings of this analysis are discussed in the following section.

Health Service delivery: All 20 initiatives identified (including those that have been discontinued) have a mandate to deliver health services, manage health information (described later), or both. The primary form of service delivery is tele-consultation on health issues, which may include remote diagnosis via video conferencing and imaging, and remote advice on disease management, prescriptions and/or referral. Two types of referral are practiced; generic and specific. The former is largely practiced in tele-consultation through mobile phone companies where patients/consumers are advised to attend any health facility that offers required care. Specific referral is more common in private telemedicine companies, and involves referrals to empanelled health facilities depending on the location of the caller; The (TRCL) initiative provides one example of this approach.

Among the NGOs, DNet has similar links to service provider partners, mostly other NGOs, who offer various levels of health services. Others including BRAC, the SAJIDA Foundation, and CRP use their own health facilities to refer clients for further care. Figure 3 shows the proportion of different types of service delivery.

Health Information: As indicated above, the other main use of the eHealth platform is health management, typically linked to a Health Management Information System (HMIS). Such systems play a central role in the management of the public health sector in Bangladesh. All public health facilities are networked and linked to the Directorate of Health Services (DGHS) for the purpose of periodic reporting of a range of health indicators. HMIS data on both health services and administration provides the basis for the collection, compilation and reporting of health statistics. Eight of these studied initiatives have a specific HMIS component, including four of those in the public sector.

In addition, most of the initiatives have some form of information management system to track their own activities. However, there was no evidence that any were effectively sharing information and experiences with others. Furthermore, there was not central forum to act as a repository for information sharing, except for a GoB initiative (implemented by the Directorate of Health Services that receives health indicator data from various regions of the country. In addition, the GoB has initiated a database of all public health care professionals.

Human resource for eHealth: Given the relative novelty of the eHealth sector and the lack of government policy regarding Human Resource (HR) for Health in the country, there is a lack of clarity in delineating roles and types of workers around eHealth. A major stepping stone in this regard, and an important part of providing an eHealth workforce with the necessary multidisciplinary skills and competencies, is the initiation of academic courses and researches on health informatics. Currently, only one private medical post graduate institute, Bangladesh Institute of Health Science (BIHS), offers such academic program. Beyond this, all non-government and private organizations involved in eHealth projects train their staff in line with the needs of the individual projects, ranging from basic medical trainings, to training in the use of the technical platforms, or academic training like physics, computing etc. Although some of the organizations are offering training and workshops, there is no formal approach for professional certification and accreditation yet in the country. The present pool of eHealth and mHealth human resources (HR) is therefore particularly small compared to its enormous potential and relevant initiatives in the country. The findings of this study reveal that the 16 private and NGO initiatives are employing staff as small as 2 persons, to a maximum of 75, employing varied personnel (doctors and medical assistants, health workers, management and admin staff, IT and software personnel and hotline operators).

Technology: Currently, telecommunication is the most popular technological platform for eHealth and mHealth service delivery in the country (10, 50%). This includes consultation via call center and SMS. Considering the wide client pool of the mobile operators at the end of October 2012, 98 million [16]- approximately two-third of the population, this is the predominant mode in regards to percentage of people receiving health services through various means of electronic and mobile health. The commercial and more clinical initiatives are largely using combination of internet and mobile technology, i.e. computer, cell phone, webcam etc. Activities under these initiatives include raising health awareness, providing electronic prescription, creating vaccine registry, and using videos and still images for diagnosis. Our findings suggest that video mode is least used (4, 20%) for sharing synchronous or real time information among the 20 aforementioned projects. DGHS is currently exploring the potential of using such technique for the monitoring of health human resources at various public health facilities.

Initiatives on health information systems are largely computer based software with remote and central data entry, compilation and output interfaces. Most projects have developed mobile based software or cloud based web application appropriate for their end-users and tailored to their service provision needs.

Financing: According to the global eHealth survey conducted by WHO [17] funds from public and private sector and donors are collectively meeting the expenditure for health related information and communication technologies (ICT) activities and relevant skill building training. In the National Budget of Bangladesh (2012-2013) [18, 19] the newly formed Ministry of Information and Communication Technology has allocated 2.94 billion taka for its annual development programme. The government eHealth & mHealth projects are mainly financed from the national health budget. However, the exact share allocated to these projects cannot be determined as the national budget for health does not include the associated break downs. Recently, there has been a development in implementing such projects, as two projects have been initiated by private entities partnering with the MoHFW. Considering these as an example of public-private partnership, findings revealed that public-private initiatives are funded by national and international donor funds i.e. Swinfen Charitable Trust, Rockerfeller Foundation, Johns Hopkins Bloomberg School of Public Health and others. Eleven of the twenty projects considered in this study are for-profit entities, and thus are not solely dependent on donor support. When asked, only four of the projects reported their sustainability plan. Further discussion on this revealed that since sustainability is linked to in-depth understanding of the financial profile (i.e. profit, expenditure, tax etc.), the commercial ventures were unwilling to share such information publicly or to the researchers.

Leadership and Governance: To understand the governance mechanism in the field of eHealth and mHealth the study team looked for relevant strategy and policy framework in the context of Bangladesh but failed to generate significant findings. Currently, there is no such direction for health related ICT in the country. The primary point to be noted here is that there exists no standard or widely accepted operational framework for eHealth or mHealth in the country. As a result, it is very difficult to assess the comparative health gains across various eHealth and mHealth initiatives through measures such as the percentage of people with access to these services, or changes in national health indicators. Furthermore, there has been no working collaboration between ministry of health and ministry of ICT, and therefore many of the eHealth and mHealth activities are being implemented within the sphere of respective projects, in a vertical approach.

A series of discussions was conducted to identify further gaps in the existing leadership and governance approach, and two major gaps were thus revealed. The first gap found is the lack of ICT procurement policy for eHealth sector, national eHealth and telemedicine policies [17]; the second gap concerned the absence of legal and ethical framework for eHealth regarding legislation on personal and health related data and internet safety. Thus no working indicator for quality assurance for eHealth and mHealth services exists in the country. Only 50% of the 20 initiatives have/had a working Monitoring & Evaluation Framework in place and about 25% either did or have an ongoing Project Evaluation process, however documents on this subject were inaccessible.

Discussion

eHealth and mHealth has proliferated in Bangladesh primarily in the private sector. It is also encouraging that health in Bangladesh has started exploring the wide horizon of telecommunication and associated bodies, as most of these initiatives are dependent on mobile based wireless connectivity with or without mobile phone platform. Considering the objectives, it was difficult to identify the effective eHealth and mHealth initiatives among the spotted ones. There are notable differences in the perception of eHealth and mHealth in the country. Probably that has resulted into diverse design and approach in the initiatives thus describing the central factor(s) contributing to effectiveness of an initiative became rather impossible. It is quite encouraging that the government of Bangladesh has stepped in this area early and has gained considerable ground by integrating information system and a rather slim monitoring technique. However such an early adoption of technology by the GoB warrants their active role in providing guidance and strategies which should have been the first and foremost in this regards. Introducing a simple and strategic framework during the inception of each and to the existing ones should be an ideal investment into the future of this sector. Absence of comparability across initiatives, is thus questioning the capability of eHealth and mHealth in achieving the health system goals in the country and perhaps globally.

In terms of a national e health policy and a national telemedicine policy the answer still lies unfavorably according to the Bangladesh WHO survey report. [4] The growing investment of the ICT and Telecommunication Industry/Technology has resulted in a resistance of "technophobia" as the rural poor is getting more acquainted with its features and benefits.(Chowdhury, 2009)

There is a considerable gap in the design of these initiatives when it comes to service delivery and its mode. The single most popular service appears to be tele-consultation which is probably a clear underutilization of eHealth and mHealth and its strength. While in the other parts of the world there are examples of virtual doctors and self-conducted checkup and diagnosis, inclusion of referral in both private and NGO based eHealth and mHealth initiatives holds much potential for extension of clinical services beyond geographic barriers and deserves more research in this area for appropriate understanding of its application. If properly installed, it can be used for real time end to end tracking of the referred cases which is apparently a huge challenge in the current system. Furthermore clinical services for remote and hard to reach areas on a real time basis are something that should be tested. Notification for public health emergencies and diseases are something that is yet to be explored. However it is possible to list down all such settings where this should be explored, the most important task is to conduct research and discussions to identify the attainable means of its application for the betterment of health. In addition to outline the possible designs and mode of service delivery, it is also important to document the community acceptability and preparedness of eHealth and mHealth.

Provided that in the long run Bangladesh manages to maintain an e & m health database by maintaining information technology programs, e Health Security would always be an issue that requires considerable attention. The Bangladesh Constitution recognizes the right of privacy to home and correspondence, however the existing legal framework does not fully recognize the right to privacy and there is no general data protection act. Therefore one of the important steps would be to enact and implement the appropriate strong laws and security systems so that we can eradicate consumer’s primary fear that their privacy will be violated and their health information will be used to hurt them, which would result in full participation by the mass community.

Health resource is an important issue that surfaced through this study. It is of enormous importance that there should be considerable investment in creating more capacity in eHealth and mHealth not only to design but also to run the show. In the current context, designing academic courses and related training is of utmost importance to position eHealth and mHealth as a tool for health service and integrate it with the existing health system. Furthermore a generic document to describe the required competencies to offer eHealth and mHealth based services is also very important. These will help in comparing across interventions and can serve as an important indicator for the future framework to assess the effectiveness.

Conclusion

Much has been written about the potential for m & e Health in Bangladesh. Is there any evidence that e & m health—can have a positive impact? It could be deduced as too early for a concrete consensus, because while the growing interest of the private sector in e Health suggests that there will be significant expansion into health markets in Bangladesh, reviewing the literature indicates that there is need for more research in this similar platform to gain evidence- based knowledge about the integration of both e Health and m Health in attaining health service delivery goal of the community and country.

There is critical need for International agencies to act as watchdogs to oversee e-health activities in Bangladesh. They can influence the GOB for linking e-health as ODA and recommend foreign aid requirement for e-health. Donor participation is present in various projects; however there should be more emphasis on necessitating evidence based reports.

At present, the vision of "Digital Bangladesh" guided to some extent the pace and path of e & m Health in its national policy, As already mentioned, the government has lot to do for this sector. This essentially begins with devising a strategic plan and then set a goal for this sector which will pave the route to link technology and health in the country. The government also needs to offer leadership to create a financial platform for such initiatives to be operated, irrespective of being a public, private or NGO entity. It would be prudent to invest in creating a framework that would be a "marketplace of sustainable evidence encouraging all around participation and to examine the role and potential of e Health in increasing access to competent healthcare in resource constrained settings. The framework may capture both monitoring and evaluation traits of e Health projects; where achievements and challenges can be shared through greater partnerships and collaboration with the private stakeholders and the GOB. Even policymakers may facilitate its use through explicit policy dialogue to ensure its incorporation within the health system.

The main challenge lies with the GOB recognizing sustainable evidence of the importance of ICT in Health and switching out of the traditional patterns of future spending on health. Therefore with amplified national and local partnerships between stakeholders based on mutual respect and learning supported by international agencies, projects in the long run can take the lead and own the solutions.