Health Information Infrastructure
in Developing CountriesMichael D. McDonald, Dr.P.H. Global Health Initiatives, Inc.
Executive Summary
With the liberalization of health care and telecommunications policies spreading across every continent, we are witnessing an explosion of health information systems worldwide with concomitant benefits to health and human prosperity. Some believe that "high technology" has less importance amidst overwhelming poverty and barriers to implementation in the lesser developed countries. Yet, innovative, and in some circumstances relatively inexpensive, implementations of intelligent networks (intelligent human and machine systems) are lengthening life, lowering the burden of illness, and improving quality of life and functional life capacity in some of the poorer countries in the developing world.
As the health care "nervous system" expands connecting health facilities, professionals and consumers globally, great changes are taking place in the delivery of health services. Population-based health interventions are helping to move informatics enhanced health services into even some of the least developed nations of the world. Although poverty and lack of infrastructure, equipment, and educated human resources remain significant barriers, the health information infrastructure is expanding at extraordinary rates.
The Gap Between Need & Demand
We live in a world where individuals are receiving the benefits of organ transplants and genetically engineered drug therapies, while the brain development and health of millions of children a day are living in a state of malnutrition. Space technology-enabled telecommunications will allow us to technically provide medical information on demand to anywhere on the globe. Yet, 70% to 80% of the population of the world does not utilize allopathic medicine as we know it today. These are only a few of the great diversity of challenges that we face in improving the health care information infrastructures, or nervous systems, globally where need for and the ability to demand life-sustaining and health-enhancing services often exist as worlds apart.
Two Revolutions
Two global revolutions are now underway that are transforming the health status of populations worldwide. First, health care systems are transforming, becoming more effective in improving health status at reduced costs to increasing numbers of people. Secondly, the information infrastructure is rapidly adding new functionality that transcends traditional geographic limitations.
The Global Intelligent Network
(a human/machine system)
The internet is reaching into almost every country in the world. The world wide web is doubling is users every 90 to 100 days. Within a decade, there will be over a billion people using network-enabled devices. Perhaps even more interesting and alarming to some, the number of and intelligence of these network devices is growing at a far more rapid rate than the number and cognitive capabilities of their human counterparts in this global intelligent network.
At the cross-section of these two revolutions, a globalizing health information infrastructure (HII) is expanding its tendrils into locations that were only a year or two ago thought to be inaccessible. This health information infrastructure is, in a sense, like a nascent yet rapidly growing nervous system for health care systems world-wide. The HII today is orders of magnitude more advanced in the most developed countries than a decade ago. Yet, it still appears to be almost non-existent in many of the poorest nations in the world.
Challenge
There are many challenges in the process of growing the HII even in the most advanced nations. However, perhaps the greatest challenge is building out effective health-enhancing applications resident on sound infrastructures in the developing world and especially the poorest nations. Hurdling the infrastructure and economic barriers is a substantial undertaking in itself. However, the greatest challenge actually lies in reengineering the potentialities of the global intelligent network to address the quite varying needs of the developing world -- and especially the most disenfranchised.
Progress
As difficult as this may sound to build the HII in the developing world, progress is being made. Examples of significant efforts are listed below:
River Blindness Eradication Project
The World Health Organization has been implementing a program to eliminate the Onchoscerchiasis (River Blindness) vector from the low elevation river valleys of West Africa. Now the Black Fly vector is under control partly as a result of the use of health informatics and space-based remote sensing.
COPINE Telemedicine
The COPINE Telemedicine (WHO and European Space Agency) project developed a strategic plan for delivering telemedicine to eleven countries in Africa
Zimbabwe Healthnet Surveillance
The Zimbabwe Healthnet is a 9600 baud internet-based health surveillance data reporting system which aggregates nation-wide population data in two week cycles, which is more timely than in several developed nations.Malaysia TeleHealth
The Malaysia TeleHealth project has proposed to use advanced health information systems to create community health knowledge bases and to provide health information directly to the consumer.Saudi Arabia and Kuwait
Nations like Saudi Arabia and Kuwait are experimenting with telemedicine and building out national health information systems within and around their hospital facilities.
International Commercial Health Care
Ventures
Columbia HCA, KP International, the Mayo Clinic, the Harvard Hospitals, the Cleveland Clinic among others are beginning to export health informatics intense health services into the Southern hemisphere in the form of commercial ventures.
Informatics 2000 Initiative
The Inter-American Development Bank and the Pan American Health Organization have been assembling human resources from essentially all countries throughout the Latin American region and many from the Caribbean. A few health informatics projects have already received IDB funding.HII Collaboratory for the Americas
An international collaborative work environment has be kicked off as an independent project in association with WHO and the Informatics 2000 Initiative to enhance the development of benchmarks and standards applicable within the Americas -- with a special emphasis on Latin America and the Caribbean. The HII Collaboratory proposes to assist in the development of national HII collaborating centers and model centers throughout the region.WorldPort 2000
The WorldPort 2000 project is aiming at producing complete airliftable village solar electricity units with embedded computer kiosks including cellular connectivity to the world wide web featuring health information.
Healthy Communities
Communications Toolset
The Healthy Communities Communications Toolset project is an effort to develop a highly automated mechanism for rapidly sharing self-replicating websites, tools (GIS, simulation engines, data aggregation engine, intelligent agents) and standardized core datasets. The project, now being piloted in California, has important implications for the rapid development of community health initiaives through the world.
Barriers
In many countries, there are fundamental barriers to the development of the HII. The physical infrastructure, perhaps the most obvious barrier today, varies dramatically throughout the developing world. State-owned telecommunications systems in most cases inhibit the rate of infrastructure diffusion. Similarly state-owned health care systems in most but not all cases tend to reduce variation, innovation, and technology adoption. Ultimately, even with the rapid diffusion of the technology, human resources remain the greatest barrier to success. Developing human infrastructure is often the rate determining step in health informatics.
Culture and socio-ecological factors play an important roles in the HII development process. For example, some Arabic cultures restrict access to the world wide web and in particular to certain medical illustrations of the human body. In other cultures such as Cuba or China, information flow is more restricted for political purposes. Although in all of the above, the trend is to increased information flow.
Enabling Factors
Over the next five years with the introduction of low earth orbiting satellites (LEOs), new high powered satellites and extensive satellite-based applications, information will be received from a myriad of common devices anywhere in the world. Wireless, mobile, and embedded devices are going to proliferate in societies globally with little connection needed to local infrastructure. With the continual miniaturization of silicon-based semiconductors and even more profoundly with organic semi-conductors, the price of health-related networked devices are likely to plummet.
The trend toward deregulation of telecommunications and health care systems will also tend to catalyze improvements to health care quality, yet in some cases, with negative impacts on cost and equity. Standards will play a major role in the diffusion and interoperability of systems. International standards efforts are underway on many components of the HII including the computerized patient record, master patient index, personal health identifier, object approaches, interoperability, and privacy.
Breakthroughs
HII breakthroughs are now becoming commonplace even in the developing world. Boundaries are being leaped. Connectivity is being achieved even in the harshest environments. Perhaps, this is most apparent with the explosive growth of the world wide web. But even in countries with highly restricted bandwidth, such as in Zimbabwe, projects like the Zimbabwe Healthnet are linking the national health department to hospitals and clinics throughout the province. ZW Healthnet yields epidemiological surveillance data in two weeks cycles on the country. In a world of exponentially increasing population, famine, mass migrations, environmental degradation, and social crisis, the health and quality of life of billions will become ever more dependent upon the health information infrastructure during the first few decades of the 21st Century.
Unintended Consequences
To what degree these systems improve lives will not only depend upon how innovative and effective we are in deploying technology. It will also depend upon how well we manage the unintended consequences of the Global Intelligent Network and the HII. As important as the HII is in the advanced nations, think of the implications for communities which can catapulted from a hunting and gathering or subsistence farming existence into a global information society with the airlifting of a crate that gives them immediate access to the Global Information Infrastructure and the benefits and temptations of the global market.
Our emerging cybernated health systems will need to address not only biomedical problems but rapid changes in social ecologies and the growth of information-based economies. Our greatest challenges may stem from living in a world stretched between extremes and contradictions. We may find that we can provide more and better health care, but in comparison to the rising populations and social crises in large percentages of the developing and underdeveloped world, health status may decline because of fundamental barriers such as poverty and illiteracy.
Conclusion
There is little doubt that globalizing health information infrastructures will save more lives, improve quality of life, provide bold new strategies for moving interventions upstream and as a result help to prevent illness at an unprecedented rate. What is less certain is whether the health information infrastructure will be sufficiently directed so as to stem the rising tide of suffering and muted human potential that will grow as human population expands from 6 billion around the year 2000 to between 8 billion and 10 billion by 2050. A large and expanding proportion of the world's children will be born, over the next five decades, into "Edge Cities" (cities with little or no infrastructure) built around the mega- cities in the southern hemisphere. Most importantly, a strategy is needed to deploy health information infrastructure to address the exponentially increasing health challenges within the world's most disenfranchised populations.
Bibliography "A Health Telematics Policy," Report of the WHO Group Consultation on Health Telematics, December, 1997.
Human Development Report 1993, United Nations Development Programme (UNDP) Oxford Press, 1993.
Health Conditions in the Americas, Pan American Health Organization, Sci. Pub. No. 549, 1994.
World Development Report 1994: Infrastructure for Development, World Bank, Oxford University Press, 1994.
Mandil, S.H., "The Potential Requirements of COPINE Health Sector Users," World Health Organization, November, 1996.
Moidu, K., McDonald, M.D., "COPINE: Preliminary End User Needs Assessment Study - Health Sector, Tanzania and Zimbabwe," World Health Organization, October 1998.
"Health Technolgy Linking the Americas Moving Toward a Vision: Implementing and Using Information Systems and Technology to Improve Health and Healthcare in Latin America and the Caribbean," Pan American Health Organization, August 1997.
"TELMED: The Impact of Telematics on the Healthcare Sector in Europe," Consortium fo the European Commission, Directorare General XIII, November 1996.
The Role of Technology in Reducing Health Care Costs, Sandia National Labs, October 1996.
Girardet, H., The Gaia Atlas of Cities: New Directions for Sustainable Urban Living, Anchor Books, 1992.
The World Health Report 1996: Fighting Disease Fostering Development, World Health Organization, 1996.
Brown, H., State of the World, World Watch Institute, 1997.
Van Berlo, A. and Kiwitz, Y., Information in a Healthy Society, Health in the Information Society, Akontes Publishing, 1992.