Test 2

In an era in which the state of health for the poorest countries, communities and people in the world is at best stagnant and is probably in decline, the potential value of the new information technologies for more effective health and development action can appear to be manna from heaven. With the qualities of rapid, two-way information flow, interactivity and mobility, the possibilities for improved health action stimulate and test the strategic and programming skills and imagination of international health and development workers.

There are vivid examples of these possibilities being grasped and put into action: from using PDAs as high-tech prompts for DOTS compliance to telemedicine virtual surgery that focuses the skills of doctors in many countries on one patient in a different place; and many more. However, there is also scepticism and concern. For example, will the new technologies support the bridging of the health gap between the richer countries of the north and the poorer countries of the south or will they simply broaden the gap across which any health equity bridge needs to traverse?

The detailed material that follows in this document seeks to provide summaries of a selection of information, analysis and findings related to the potential and actual role of new information technologies adding positive value to health and development strategies and programmes. The summaries are presented in neutral form – highlighting without comment the nature of the experience, essence of the analysis and key findings from any research. From this material and the full sources should you choose to review them, you will be able to draw both your own general insights and conclusions and any particular information, insights and ideas that can help to improve your particular health and development work. The overall sections are grouped as follows.

First, three set of analysis papers – supporters, detractors and middle roaders.

Second, classification of these think-pieces across a range of health and geographic areas.

Third, summary descriptions of a number of programme experiences using ICTs to help advance their work. For better understanding and access we have attempted to organise and classify these according to the nature of the programme intervention: Database and Resource Centres; Social Development, Education and Advocacy; Networking and Dialogue; and, Telemedicine and High Medical Tools.

Fourth, those programme experiences are also classified according to a more extensive set of groupings.

Finally, some data has been gathered and compiled on the health status trends that provide the ‘ground quality' for all health action, including by those using or seeking to use ICTs as part of their strategy and programmes.

As part of this process The Communication Initiative has been asked to highlight it's assessment of the material collected, reviewed and summarised – specifically the major gaps and issues in harnessing the specific power and qualities of ICTs for more effective health action. That assessment follows, in very brief form for easy access and use. However, before highlighting these observations it is important to stress that this is just one reading from the material that follows. We would encourage everyone to reach their own conclusions.

Top 10: Strategic Issues and Gaps

From the reading of the critical observations and experiences that follow, as well as a general overview of this field derived from The CI web site www.comminit.com we suggest that the following are core strategic issues and key gaps that need to be addressed.

1. Issue: Voice vs. Information

The very nature of ICTs lends them to quick, inexpensive and rapid information dissemination. Emails get to the recipients instantly. Web sites can be viewed at any time. MSN and other instant messaging services mean that you can contact people when you want [providing they are online – an issue to be addressed later]. This capacity of the ICTs has seen the people with the combination of access to the new technologies and an available reservoir of information reorienting their information and communication strategies to better ‘push' the information that they regard as essential ‘out the door' to the people and organisations that they think will benefit from that information. So, for example, the international health and development community is full of organisational web sites and email magazines that push the experiences, services, products and capacities of that particular organisation: new research results, training opportunities, programme developments, papers and other documents, fund raising successes etc. They are very organisation centric.

However, there is a particular issue with this development related to the issue of ‘voice' – whose ‘voice' gets the added prominence through the qualities and capacities of the ICTs? The answer of course if the northern based agencies – the richer organisations with both [a] the funds, capacities and connectivity to develop the web sites, databases and email list serves that can promote their view of the international health world and [b] a ready supply of information that can easily be made ‘web-ready' in order to ‘populate' their ICT processes.

Where there appears to be much less attention is on the use of another very strong capacity of the ICTs – the ability to swiftly communicate a range of different ‘voices' related to any issue. In this case the voices of those directly experiencing or threatened by health issues. ICT and Health processes that position themselves with the primary role of ensuring that the voices of people that are engaged in policy development, programme review, critical thinking and programme management, are few and far between. The ‘pull' role for ICTs – pulling more diverse and grounded groups of people into the functions just described is notably absent as a central, primary strategy for most organisations using ICTs.

This is a major weakness. As can be seen in the health trend data, many of the key indicators are heading in the wrong direction – from HIV/AIDS and TB through malaria, child immunisation rates and even polio. Overall health strategies and programmes need to be continually reviewed and amended. Engagement of those directly affected would improve strategic thinking and programme performance – helping to ensure relevance and ‘fit'. The ICTs have strong capacities to support these processes.

Gap 1: Insufficient prioritization of the use of ICTs to increase the ‘voice' of people directly affected or threatened by health issues in policy development, programme review, critical thinking and programme management roles

2. Issue: Technical vs. Content

In the South, the international development field has promoted and experienced what appears to be a tornado of activity on the technical aspects of ICT but only a slight drizzle of action in developing content for ICT processes. The balance between the two may need correcting. This is an important underpinning to health and ICT action. In this case, technical refers to the infrastructure for ICT operations – from providing computers and funding telecenters to national ICT policies, broadband and satellite links. Content is what is transmitted utilising that infrastructure – the content in pages on web sites, e-magazines, emails, etc. Of course the technical is a necessary prerequisite to support the content flowing and much remains to be done [maybe always will remain to be done] as we will observe later. Equally, having the technical infrastructure with little or perhaps irrelevant content is an unhelpful situation.

Increased support is needed for people experiencing and working on health issues to utilise the ICTs to:

1. Create health content from their experience relevant to their contexts and issues for their neighbourhoods, communities and countries
2. Tell their stories
3. Communicate the lessons from their experiences, and
4. Support each other with their health actions.

This is an extension of point 1 above with an emphasis on decision-making and critical review. Here we are more concerned with ICTs as part of programming action for local knowledge – the development and communication of ideas, information and thinking specific to particular contexts, by and for the people in those contexts. The culture around health [compare for example the customs related to birthing practices and the implications of those customs for maternal mortality reduction strategies] is a vital factor for improved health action. ICTs can play a very important role through the development of local content. Even though the ICT infrastructure is not all pervasive [and may never be] and the main beneficiary at this stage may be health workers rather than local community members, it is vitally important to give such health content development priority at this time.

There is a pressing need to train and foster more local content generators. Human capacity building is required in both hard skills (like networking) and in human communication skills like marketing, journalism, research and leadership. These combinations of skills will result in individuals who are well equipped to both transform the information on the Internet and to contribute to that larger pool of knowledge. This does not mean that the developing world requires the creation of a small cadre of its own experts, but that models should be developed for larger group contributions to the knowledge base.

Gap 2: Insufficient attention in ICT strategies to health organisations prioritising local content development.

3. Issue: Discrete vs. Integrated Communication

There can be a tendency, perhaps because the new information communication technologies are so new, different and exciting, to view them as separate to and sometimes replacing the existing communication and information channels and media. Perhaps we could call this the ‘new toy' phenomena. In many cases there appears to have been a drive to focus attention on the new technologies in isolation from the existing work through radio, print, TV, traditional drama, theatre, live music, art and other communication forms. This is understandable. The new technologies appear to promise so much with their scale, flexibility, inherent multi-media capacity, and comparatively low cost. This would, however, be a considerable mistake. The strategies and programme experiences that are beginning to meld new and older communication processes may have the more promising approach.

Widespread, individual connectivity of the type that is commonplace in the West is not feasible, realistic, or even desirable for the developing world. In order for the new ICTs to be most effective and to gain the broadest possible audiences, they are best combined with other media forms – for example, radio. Radio is incredibly widespread throughout the developing world and in Africa it represents the only truly universally accessible medium for the majority of the people. Radio is the ideal intermediary for the poor, geographically dispersed, and illiterate portions of the population to gain access to the information and knowledge that is stored on the Internet and in the host of other resources enabled by ICTs. The benefits that radio can convey as an intermediary also go beyond the provision of widespread access. Radio stations and their staff can act as search engines, locating the information that may be of use to the community; they can act as translators, deciphering the voluminous but largely unilingual content of the internet; and they can provide both local and international context to the information that they pull off the web. In this way, recipients of the information can develop a better sense of how their daily existence can benefit from the information and also gain a better sense of how they fit into the global economic, social and political system.

Gap 3:Insufficient incorporation of the new information communication technologies with other communication technologies.

4. Issue: Programmes vs. Trends

The incorporation of the new technologies as components of the overall action to improve health status has followed the somewhat traditional specific programme activity approach that is so common within international development: telecenters are created; web sites are built; networks are wired; chat rooms are formed and facilitated; and other specific, discrete activities are undertaken. This is a common thread through the programme experiences described and the nature of most of the strategic analysis of the papers summarised. These developments are of course, in some way following a trend that lends itself to a new form of programme action. Without a national trend to Internet use it would not be possible [nor desirable] to create community telecenters – be they exclusively new technology based or integrated with other communication technologies. However, it is necessary to wonder if, in developing such specific initiatives that consume major time, attention and financial resources, the international health movement has missed riding a very significant trend that is both affecting how people communicate and ways in which they may gain access to the change tools for improving health status. For example, there has been a major trend towards Internet cafes or cyber cafés [called different things in different countries – they are often very basic in character] in many countries including many of the poorer countries in the world. However, very little information in about these processes came to light on, for example, health partnerships with the owners and managers of these establishments. Likewise, there is a similar situation with mobile or cellular phones. Over the next decade these will become so much more common than fixed line phones that the latter technology may be consigned to the dust heap. However, there is little effort, it appears, from this review of the programming and strategic thinking, towards brokering partnerships and alliances with the mobile/cell phone companies to explore ways to harness this trend for better health. In both cases [and there are other examples] the effort to develop specific, discrete ICT initiatives and programmes has diverted time and skills from attempts to capture and harness powerful trends for significant health gains. Wireless is most likely the next major trend and opportunity

Gap 4: Insufficient strategic thinking and action that seeks to harness the overall new technology trends – e.g. Internet cafes and mobile phones - for health action.

5. Issue: Programmes vs. Structural

A similar dynamic exists in relation to the comparative efforts focussed on new programme development compared with addressing structural issues affecting the new technologies. Though this is not directly a health issue it does undermine the potential for effective health action utilizing new technology opportunities. For example, there is little concerted effort within the international health field to address an issue such as the cost of a dial-up connection or the duties and taxes on imported hardware and software. Whilst international development funders are [directly or indirectly] supporting health focussed local and national NGOs and Ministries of Health to significantly upgrade their new technology capacities, local structural issues are significantly hampering the effective use of those technologies. And, whilst funders are supporting UN agencies and international NGOs to be more efficient and effective through the use of the new technologies, much of their effort is watered down because of local structural issues.

Effective action to harness and utilise the new technologies as a significant ally in the fight for better health may come through lower internet access rates within a country or community rather than establishing a specific organisational web site. It will probably be more effective for people's health in a community or country to provide young people with email and Internet skills rather than funding and running a specific online health campaign on a particular health issue. Subsidising the local Internet or cyber café so that more people can use this process to access health information at cheaper cost might be a better and more sustainable use of resources than creating a new purpose built multi-media telecenter. One of the great values of the new technologies is that people can access the health information and ideas relevant to them in their context. This applies at an individual level and also at the level of health workers. Changing the structural conditions to better support more people accessing and contributing knowledge, and discussing and debating health issues relevant to them, is crucial to effective ICT action on health.

Gap 5:Insufficient attention within the international health community to the new technology structural issues – pricing, taxes, access, controls, etc – that significantly undermine the value of the new technologies for health action.

6. Issue: Plans vs. Space

One of the great values of the new technologies is that they can be used for almost anything and everything. If you need to establish a place to chat with a group of people - you can have it. Want to publish a magazine – go to it. You desire a real-time forum with colleagues – no problem. Wish to store and retrieve information, undertake research, run an advocacy campaign, link to others in your field of work – nurses, doctors, epidemiologists, people experiencing the same health issue as you, coordinate an activity, map trends and many other activities – then the new technologies are for you. One of their great values is that they provide a new space for people to better achieve their goals. With the new technologies – through essentially one technological instrument – it is possible for the person at the mouse, keyboard or handset to decide what they wish to undertake on any day. And to do something different the next day! This ‘space for the people doing the direct work' approach to health action runs somewhat counter to the normal practice of management and funders negotiating, agreeing and defining detailed often long term plans of action. There is an inherent clash between the culture and potential of the technologies for improved health action and the culture and expectations for ‘proper' development practice.

Present development practice stresses specific planned outcomes to which everybody involved commits to work towards and gears their work routines and priorities to achieve. The process of developing these plans goes by different names in different funding and technical support organisations. But the intent is always to discretely define the specific measurable outcomes from a planned [and funded] activity/initiative.

The effective use of new technologies for health gains may require a very different process. The ICTs have two very important qualities that are vital for, in this case, effective health. They place the control of the process in the fingers of the user. That person – be they a health advocate, health worker, health manager or someone experiencing or being challenged by a health concern [or perhaps exploring a health opportunity] can use the new technologies to respond to their specific interests and context. This is vital for good health action. The information and ideas they access and contribute can be done in real time – when it is relevant to them. Additionally, the new technologies have the capacity [presently significantly under-utilised] to be interactive. They support debate and dialogue, exploration and assessment, which are also much desired traits when so many of the healthy issues we face require creative, locally relevant action in order to be successfully addressed. The days of uniform, global, top down strategies and programmes may have passed.

The new technologies provide the space for these required processes to be implemented relevant to health. To fit the new ICTs into a health planning box that requires specific, planned outcomes may very well neuter the things that we require most for improved health action.

Gap 6: Insufficient emphasis on the new technologies as a vehicle or platform that provides a space within which health actors can define the plan and direction they wish to follow rather than having to follow a predetermined management plan for how the new technologies will be used on health issues.

7. Issue: Potential vs. Proof

There is a general lack of dialogue and writing specifically on the topic of ICT4D project evaluation methods. More specifically, there is a shortage of tools to assist programme managers and agencies to evaluate weaknesses in their programme design and make mid-stream corrections to their programme frameworks. Directors should not be bound by immutable plans that were established at the outset of the project. Many pilots are started with short, one to two year funding outlines and high expectations for rapid results. If the initial plans are flawed, they will require rapid evaluations and contingencies for quick and localized changes to the plan if the project is to be salvaged. This may well mean changes are required in the first 2-4 months of any given project, because by the time the half-way mark for the initial funding rolls around, the programme may well be beyond the point of return. Many of the evaluations that do take place are after the fact – once the programme has been deemed a failure and had its funding terminated. These types of evaluations, while useful as learning tools for future designs, are problematic because of the impressions that they leave with donor agencies who may be more interested in seeing concrete results than they are in the failed programme's contribution to the larger body of knowledge.

One of the most salient observations from the material attached is the importance of localized improvisation and adaptation for project success. If programme designs remain open-ended, and local participants and stakeholders are drawn into a process of evaluation very early into the project there may be opportunities to rapidly identify the components of the project that are likely to lead to failure if left in place. Localized solutions to the identified problems can then be developed and the original design framework can be appended to reflect these early evaluations.

But how are all the other stakeholders – usually those up the hierarchical chain such as head offices and funders – going to respond to initiatives aimed at rapidly revamping programme frameworks that were carefully poured over by academics and policy makers for months or years prior to implementation? Probably not well. Certain organizational changes are likely required prior to adoption of a new set of “on the fly” evaluative and adaptive tools. One must ask, however, how bureaucratic is the development community? It obviously depends on what organization one is talking about. Some are bound to rigid but highly accountable public service models, while others are shaped more like small business enterprises, flexible but footloose. Yet, which organizational model is more likely to meet with project success and develop sustainability?

In even shorter supply than the literature on project evaluation is literature on organizational evaluations of implementing agencies. The new public management (NPM) trends that are in ascendancy in the West include a growing body of literature on organizational reform and design. While many members of the public service and development communities are extremely sceptical of the intentions and appropriateness of NPM for development projects, there may be lessons to learned from its evaluative models that stress early intervention, decentralized decision-making, and outcome-oriented design.

Clearly, there is ample room for debate and dialogue in the area of evaluation tools, methods and models, and regardless of ideological stripe, most agree that more research and study is warranted. Evaluations are critical learning tools for future programme design, but they should also be tools for saving and restarting current projects that have lost their way (or that never had their way in the first place). Networking and dialogue projects like the ToolxCHANGE (click here for description of the project) may prove invaluable in generating new methodologies for evaluating project designs, implementations, and agency organizational structures.

Gap 7: Insufficient attention paid to evaluating the impact of the new ICTs on health

8. Issue: Broad Economic Development vs. Specific Health Focus

In the recent Lancet series on child health, one of the 5 papers looked at issues related to the relationship between equity and health status. They concluded that improvements in equity would have much greater impact on health status than any number of technological interventions and health specific “campaigns”. Therefore the “leapfrogging” thesis that plays an important part in efforts to build information economies in the developing world requires serious examination and debate. Authors on the one side argue that the creation of an information economy in the developing world is necessary if they are ever going to be able to catch up in terms of the basic standards of living common in the West. The necessity of this transformation is reinforced by their declining comparative advantage wrought by cheap labour costs. The new global economy is moving away from geographically concentrated, labour intensive industries, and countries that attempt to adhere to this “old” model of industrial development will find themselves continuously marginalized.

But is the rapid emergence of an information economy realistic given the shape of the emerging global economy and trade structure? The innovation and R & D flows and energies that are at the heart of the information revolution and Knowledge Based Economy (KBE) are strictly contained within the developed West and there is little chance for the developing world to access these opportunities without a long period of internal development. Advocates who place their hopes on concepts like technology transfer have clearly not been paying attention to the tremendous growth in the field of Intellectual Property Rights (IPRs) and other agents that almost completely inhibit the potential for the widespread utilization, appropriation, adaptation, and reinvention that would have to accompany any developing economy's bid to “leapfrog” into a fully knowledge-based economy.

And where does the comparative advantage for the developing world lie? At present, they cannot achieve advantages in the required research and development faculties – they simply do not have the human capacity, venture capital markets, and research institutions that are hallmarks of the KBE. The boom in ICT hardware electronics manufacturing and software development that is taking place in places like India (though in limited pockets) is vital to development but will not rocket the majority of the population of these societies into a place that even remotely compares with Western standards of living. That precious comparative advantage for the majority of the countries in the developing world can only realistically lie in sustainable agriculture. Yet this avenue is blocked to them by the maintenance of agricultural protectionism throughout Europe and North America. Western farming subsidies are one of the biggest barriers to global development and efforts to remove them are progressing at a slow pace. But, while there is a current move to remove protectionism for basic agriculture and industry, the trend is for increased protectionism in the high-tech and ICT fields.

These issues are highly relevant to future health status. As the Lancet article indicated, given the importance of knowledge and information to equity, they may be more important to health status than specific health interventions. However, health issues rarely feature in knowledge based economy debates. They should.

Gap 8: Insufficient attention to the health benefits from growth in equity of information and knowledge access and interaction through the new technologies

9. Issue: Independent vs. “Part of” Programmes

ICT projects appear to be more likely to be successful when they are added as enhancements to pre-existing projects with established goals and guidelines for outcomes. Projects aimed at expanding and introducing basic ICT infrastructure should have some other end in mind than simply providing connectivity. It is important to ask how will connectivity contribute to real enhancements and improvements in the quality of life for people living in the region.

There is no question that many existing projects, especially in fields such as health and medicine, can benefit from the addition of ICT tools and processes. Organizational efficiency and communication can be enhanced, and entirely new processes such as tele-health services can entirely change the way that providers go about reaching their established goals. Community groups with pre-existing mandates will also benefit from the myriad of networking and data collection opportunities provided to them by a simple Internet connection. But what of the telecentres and wired community access points that are initiated just to bring connectivity to some remote corner of a poor country. Is it clear how that access is going to help development? What will the goals and projected outcomes of the project be? Measures will probably be based on the number of community members that access the facilities during a certain period of time – but what will the measurable benefits be from their attending such a centre? Projects need to have another set of goals beyond getting a larger portion of the population to sit in front of a computer for two hours a week, because this is unlikely to bring about major change in their lives. There is no question that access to a larger pool of information is useful, but it is much more useful when that information is being collected and considered with some future action in mind.

It is also relatively logical to believe that if a programme has already achieved a relative level of sustainability, that it is more likely to be able to maintain the ICT enhancement component over a longer time period as well. Sustainability generally indicates that the organization is fiscally responsible, that its mandate has the support of both funders and service recipients, and that it has effective management. All of these features are key to the successful implementation of ICT projects. Ongoing programmes and their management staff may also be able to prevent the implementation of wasteful projects. People that have been doing a job for a while will know best whether or not ICT enhancements are going to work in their particular field. They may simply say that ICTs will not contribute to their mandate and that they would much rather see funds directed towards some other project,

Furthermore, even if the ICT-based enhancement project fails to achieve its particular goals, the organization that attempted the project lives on and is able to provide feedback about the strengths and weaknesses of the project to a larger audience over a longer period of time. It may have the opportunity to participate in several ICT enhancement projects, providing a relatively controlled environment for research on the effects of such implementations. For example, one research project detailed in the summary (Austin et. al., click here) was examining the use of technologies for community health care providers. The researchers gained valuable information from feedback about an ICT pilot project that the organization had participated in nearly 2 years prior. It was decided that the pilot project was not worth pursuing, but the organization and its staff retained their knowledge about the pilot and were able to pass it on to other, unconnected researchers at a later date. The staff of pure ICT projects that fail are likely to disperse and move on to other endeavours preventing the ready collection of their combined knowledge concerning the project. The organization that survives an ICT pilot may also be able to act as a “lab” for future projects. Researchers can now control for variables such as staff responses to technology, organizational structures, and various other quirks that are difficult to account for when a pilot is applied to a previously unknown group.

Finally, the level of acceptance amongst a recipient population is likely to much higher when a pre-established programme that has legitimacy with the local community is at the centre of an ICT initiative. Service recipients are likely to be sceptical of pure ICT projects (with questionable real benefits) that are parachuted into their communities, especially if the already established programmes (that they see real benefits from) are under-funded.

Gap 9: Insufficient attention to incorporating ICTs as an integral part of ongoing programmes.

10. Issue: Direct vs. Intermediaries

A significant observation that has emerged from his study is the importance and necessity of intermediaries for ICT projects. Intermediaries can come in many forms, several of which have been already noted in earlier points of observation, but their common thread is that they transform the vast wealth of the information on the Internet and the other channels of global information access into knowledge that has immediate and tangible use for developing peoples. The radio station and its host are intermediaries; the nurse who attends to the patient during telemedicine exercises is an intermediary; the teacher who guides children through computer and Internet based learning exercises is an intermediary; the village telecentre operator who understands and conveys the knowledge about the necessary communication protocols for phones, faxes and the Internet is an intermediary. In all of these cases and in many more like them, the intermediary is the vital link between the information seeker and the information.

It is thus absolutely necessary that project designs consider the role of the intermediary first and foremost, before the role of the technology. The very best intermediaries will be able to work with the technology that is available and adapt it their specific situation, rather than attempting to restructure their environment around the demands of the technology. The time and money spent on developing training programmes and curricula for all of the various types of intermediaries is crucial and more valuable than that spent on technological adaptations and modifications. Intermediaries need to be innovators, translators and contextualizers and they must be supplied with the tools necessary for such a task.

Recipient-intermediary relationships are also important determinants of social access to information and technology. The Graemeen Bank (click here) telephone project has observed the importance of having women as the operators of the village phones. These women are intermediaries that are accessible to the entire population of the village – a characteristic that is of value to the overall sustainability (in terms of the service market size) and reach of the initiative. Similarly, technological devices that enable female health care workers to enter family homes equipped with vast amounts of diagnostic and preventative information and tools, broadens access to the benefits of the new ICTs.

Because of the significance of intermediaries, policy and programme design should increasingly look to identify the position and roles of the intermediaries first and then complement them with appropriate technological solutions. These facilitators of information should be enabled to make adjustments and modifications to designs and implementation strategies and as well as the reassessment of project goals and outcomes.

Gap 10: Insufficient attention is paid to the vital role of intermediaries in implementing effective ICT for Health processes.

Conclusion

The observations above are drawn from an overall reading of the full material that follows: the analysis papers, case experiences, health trend data and categorization. They are the observations from The Communication Initiative. Others reading the same material may reach very different conclusions concerning the most important issues and gaps facing a more effective harnessing of the ICTs for improved health status. Such is the dynamic and vital state of ICTs for Health.

Click here to go back to the table of contents, or navigate above by clicking on "next page".