Prof. Leonid Androuchko Improving access to healthcare services by using information and telecommunication technologies. Information Session on « Digital Health for Rural Communities: Potential, Trends and Challenges » ITU, Geneva, 17 September 2010 Prof. Leonid Androuchko ITU-D Study Group 2, Q14-3/2: Telecommunications for e-Health International University in Geneva

Health and ITU What are the relations between Health and ITU? What is the role of ITU?

What is eHealth? (1) The advances in medical science, biomedical engineering on one side and information and telecommunication technology on the other side are offering today wide opportunities for improving access to and quality of health care.

What is eHealth? (2) eHealth is an umbrella term for health-related activities, services and systems, carried out over a distance by means of information and telecommunication technologies.

International Telecommunication Union(1) The introduction of eHealth services in developing countries requires multidisciplinary collaboration, with active participation of both sectors:telecommunications and health care.

International Telecommunication Union (2) ITU is active in the field of Telemedicine/eHealth from 1994, when developing countries during the time of the First World Telecommunication Development Conference in Argentina asked ITU to study this question from the angle of interest of developing countries. From 1994 there are two streams of ITU complimenting activities: ITU/BDT Development Programs, ITU-Development Sector Study Group

International Telecommunication Union (3) From 1994 till 2010, ITU implemented a lot of pilot projects, missions, conferences and seminars in developing countries in order to demonstrate potential benefit of eHealth/telemedicine services and disseminate information on how to improve access to medical services for people living in rural areas. Resolution 41 of ITU World Telecommunication Development Conference, which took place in 2002 in Istanbul, Turkey, recommended to all countries to create national eHealth Committees or Task Forces for such cooperation and coordination.

WHO The World Health Assembly in May 2005 officially recognized eHealth and adopted Resolution WHA 58.28 establishing eHealth Strategy for the World Health Organization.

ITU, WTDC 2010 Hyderabad,India Resolution (COM3/5) was approved on « Improving access to healthcare services by using information and communication technologies ».

ITU-D Study Group 2, Q-14 The main goal of the study is how to assist developing countries in the introduction of eHealth services and solutions, covering the technical part. This is the unique international study group in the ITU-D SG2, Q14 dealing with needs of developing countries.

How healthcare service in rural areas could be improved? eHealth or Telemedicine is the one practical solution which exists today. Access to healthcare services could be provided via telecommunication networks: fixed terrestrial network, mobile network, satellite network.

International Telecommunication Union Experience demonstrates that there is no single solution that will work in all settings. The complexity of technologies and the complexity of needs and demands of healthcare suggests the gradual introduction, testing and refining of new technologies.

Mobile telecommunication in developing countries The number of mobile phones in many developing countries is drastically increased during the last five years offering technical platform for many mobile eHealth services to be organized.

Mobile network coverage in selected countries (ITU, 2007) Combodia 87%, Gambia 85%, Guinea 80%, Kenya 77%, Pakistan 90%, Rwanda 90%, Senegal 85%, Togo 85%, Uganda 80%, Zimbabwe 75%.

Comparison of mobile and fixed phones (Source – ITU)

Mobile networks in selected developing countries (Source – ITU )

Mobile eHealth in rural areas There are two solutions: Mobile phone can be used for management and consultations related to medical services. Mobile eHealth care clinics/units traveling in rural areas from one village to another and connected to nearby hospital by wireless communication for consultations.

ITU-D Study Group 2, Q-14 It was decided to prepare the questionnaire and ask the opinion of medical staff in developing countries about Telemedicine and eHealth. It was also a question asking participants about their view with regard to the implementation of eHealth services.

ITU-D Study Group 2, Q-14 The study was done in the following countries: Pakistan, Uganda, Bhutan, Sri Lanka, Saudi Arabia and recently in Mongolia.

How developing countries are informed about eHealth? (1) The health care administrations in developing counreies are not well informed about potential benefit of eHealth services.

How developing countries are informed about eHealth? (2) The Telemedicine Group of ITU-D SG 2 made a study among medical staff in five countries and found the following level of information: Pakistan-61%, Mexico-18%, Uganda-73%, Bhutan-31% and Malaysia-66%. This average level is still low.

ITU-D Study Group 2, Q-14 In favor of eHealth services Uganda – 96.6% Pakistan – 86.5% Bhutan – 87.5% Sri Lanka – 81% Saudi Arabia – 90.7% Mongolia – 77%

What is it nesessary to speed up the implementation?

What is it nesessary to speed up the implementation?

Why eHealth services are not implemented? Main obstacles: Lack of Government policy Lack of the knowledge about eHealth successful projects Lack of training at all levels

ITU Strategies for e-Health 1. Advance the establishment of ICT infrastructure 2. Provide tools for the development of national e-health strategies 3. Promote cooperation among relevant stakeholders 4. Facilitate information exchange In accordance to the mandates of the Geneva Plan of Action, ITU-D is implementing the following strategies to promote the introduction e-Health applications in developing countries. 26

1. Advancing ICT Infrastructure Connecting the unconnected remains a challenge: High speed broadband connectivity, needed for key e-health applications, is expensive or unavailable Insufficient local content Traditional business models often do not support the needed investment High speed broadband connectivity is needed to transmit the large amounts of data and high quality images required for key e-health applications Traditional business models, especially in rural and remote areas, often do not support the needed investment Insufficient local content is available and too few people have training in the required technologies eHealth/Telemedicine network It is a key platform for eHealth services It has to be based on existed fixed and mobile telecommunication infrastructure Integrated modular approach It has to be designed and controled in line with specific requirements for medical applications: security and reliability. Few trained people in the required technologies 27

Wireless Broadband Initiative Objective : Ambitious ITU initiative to expand broadband access in underserved areas of Africa ITU’s initiative: ITU is working with governments and other partners Expected outcomes : Develop and deploy wireless networks Guarantee capacity for schools and hospitals Train local experts and build human capacity Develop ICT Applications: e-health, e-education, e-government We are launching an ambitious initiative to expand broadband access in Africa Each partner has an important role to play: Industry will develop networks, allocating some capacity for public use Governments will handle permits, licenses, policy and regulation And, ITU will assist countries with project management, capacity building 28

2. Providing Tools Practical guidelines for the development of national e-Health strategies will developed in collaboration with WHO and the World Bank in 2010 The Guidelines for National e-Health Strategies : Methodology to assess actual Health System Status, Needs and Action Priorities An integrated Action Framework covering: Infrastructure, Applications, Financing, Governance, Legal and policy, Human Capacity, Information quality Guidance on how to set eHealth targets, benefits and Key Performance Indicators To guide the implementation and use of e-Health capabilities in a manner that fits identified national health priorities, ITU is working closely with WHO and other key players in a series of tools that underscore principles, strategies and resources that Member Countries can use when developing their eHealth national plans. Guidelines for National e-Health Strategies: - Developed in a series of modules, the Guidelines will provide recommendations for and examples of best practices relating to the life-cycle of national e-health strategies,needs. Why are National eHealth Strategies so important? It is necessary for the Strategy to demonstrate that projected eHealth applications can be beneficial: -to the patient (in terms of time, quality care received; cost, etc.), -to the medical staff (in terms of productivity, competencies, etc.) -to the community (in terms of public health for everyone) 29

Providing Tools (cont.) Practical guidelines to map e-Health infrastructure to desired outcomes Survey some of the major Tele-health initiatives in India comprising basic information about activities and infrastructure Grouping of activities across care cycle within various services Map of Activities and diseases being addressed by those activities, correlated to corresponding infrastructure being utilized Map the gaps between the desired and existing facilities as evidenced by some of the efforts The concept of ICT intervention in Health Care delivery has attracted international initiatives with huge budgets as a mechanism for bridging the global digital divide with equitable care delivery. However, the extent of proliferation in delivery of timely, efficient and comprehensive care in developing countries is relatively very low in spite of such efforts when compared to the spiralling of health related economic loss and associated erosion of human values. The learning from various experiments lying in fragments can be aggregated and utilized to identify realistic constraints and requirements of infrastructure for an orderly process of modernization avoiding loss of time and resources. This needs a systematic approach of classifying the activities various initiatives are pursuing within the care cycle within the infrastructure facilities and constraints of their target demographics, so as to understand what can be done with different levels of infrastructure as evidenced by the initiatives, instead of force-fitting technologies to medical care. Scope of the paper With this background context, from an ICT perspective, we try to map the major transactions at various stages of the care process from various initiatives in a target eco-system. We then bunch the transactions in terms of the activities such as consultation, counselling, surveillance, diagnostics, treatment, therapy, medication, etc. We then map technical requirements of infrastructure being adopted for such activities based on constraints stemming from the diversity in economy, language, culture, literacy, technology, etc. of the target ecosystem. To the extent possible, we also map the gaps between the desired and existing facilities as evidenced by some of the pioneering efforts. While the results may not represent a total resolution of the problem, it is expected lead into new insight in terms of infrastructure planning. Deliverables Survey report of some of the major Tele-health initiatives in India comprising of basic information about activities and infrastructure (Week 4). Classification and grouping of activities across care cycle within various services as practiced by the initiatives.(Week6) Map of Activities and diseases being addressed by those activities, correlated to corresponding infrastructure being utilized (Week 7). Full Paper ( Week 8) Provide insights in terms of infrastructure planning for eHealth. 30

3. Promoting Cooperation The introduction of e-Health applications requires multidisciplinary collaboration ITU facilitates the establishment of public-private partnerships All countries to create national e-Health committees or Task Forces for cooperation and coordination The introduction of e-Health applications requires multidisciplinary collaboration, with active participation of telecommunication operators and health care professionals Resolution 41 of World Telecommunication Development Conference (Istanbul,2002) recommended all countries to create national e-Health Committees or Task Forces for such cooperation and coordination ITU can play an important role in achieving this goal. It provides an environment where representatives of government, the industry, universities and research centers from 191 countries, composing its membership, are brought together under a single roof to facilitate the exchange of best practices and the evaluation of diverse strategies. Based on Resolution 41 World Telecommunication Development Conference (Istanbul, 2002) 31

Cooperation: Digital He@lth Initiative (DHI) ITU is co-chairing the DHI, a unique, multi-stakeholder collaboration between the ICT and healthcare sectors : Harness digital health care solutions for scaling up Interventions in even the most resource poor settings. Map the current state of play in this field Develop an economic model for policy-makers and practitioners Put in place a partnership platform for fast and high impact country-specific projects of regional importance Digital Health Partnership Space Business Organizations: Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC), Global Alliance on Improved Nutrition (GAIN), Commonwealth Business Council (CBC), African Business Roundtable (ABR), International Business Leaders Forum (IBLF), Global Information Infrastructure Commission (GIIC), World Economic Forum (WEF), International Aids Vaccine Initiative (IAVI), mHealth Alliance Foundation Organizations Rockefeller Foundation, Wellcome Trust, Bill & Melinda Gates Foundation, Carso Institute for Health, United Nations Foundation, Vodafone Group Foundation, BBC World Service Trust, Mo Ibrahim Foundation, Aga Khan Foundation, Grameen Foundation, Clinton Global Initiaiative, Open Society Institute, MacArthur Foundation, Novartis Foundation for Sustainable Development Private Sector Organizations Alcatel-Lucent, BT, Telefonica, France Telecom, Verizon, Ericsson, Nokia, Motorola, Samsung, Qualcomm, Cisco, Google, Oracle, Microsoft, Intel, C-SAM, Sun Microsystems, Fujitsu, Sony, Lenovo, HP, Vodafone, Zain, Pfizer, Merck, Novartis, GSK, GE Healthcare, Nokia- Siemens, Siemens Health Systems, IBM Healthcare, Healthanywhere, IgeaCare, Proctor & Gambel, Johnson & Johnson, Pepsico, Coca Cola, Unilever, Kraft, Nestle, MTV, VH1, WPP, Grameen Solutions, Voxiva, KPBC Academic Institutions and Civil Society The Earth Institute at Columbia University, Columbia Institute for Tele-Information, Imperial College London, Harvard University, Oxford Health Alliance, Scientists Without Borders, IIT Mumbai, MIT, African Medical and Research Foundation (AMREF), Help the Aged, CONGO, APC, One World, Panos, Overseas Development Institute, International Council for Caring Communities, CONCERN, Global Forum for Health Research, COHRED International Donors Department for International Development (DFID), Swedish International Development Agency (SIDA), Canadian International Development Agency (CIDA), Swiss International Development Agency (DEZA), Norwegian International Aid Agency (NorAid), Japan International Aid Agency (JICA), Ireland Aid (IA), European Commission (EC) International Organizations World Health Organization (WHO), Global Health Workforce Alliance (GHWA), The Partnership for Maternal, New Born and Child Health (PMNCH), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), UNAIDS, United Nations Environmental Programme (UNEP), United Nations Development Programme (UNDP), World Food Programme (WFP), International Telecommunication Union (ITU), International Labour Organization (ILO), United Nations Office for Partnerships (UNOP), The Global Fund to Fight AIDS TB and Malaria (GFATM), GAVI Alliance, Organization for Economic Cooperation and Development (OECD), Commonwealth Secretariat, Commonwealth Telecommunication Organization (CTO), New African Partnership for Development (NEPAD), Development Bank of Southern Africa (DBSA), African Development Bank (AfDB), Asian Development Bank (ADB), Inter-American Development Bank (IDB) European Bank for Reconstruction and Development (EBRD), World Bank Group (WBG), International Finance Corporation (IFC) Put in place a partnership platform for fast and high impact country-specific projects of regional importance 32

Cooperation: ITU Study Groups on e-Health Study Groups (SG) dedicated to e-Health related issues : ITU-D SG 2 Question 14-2/2: Telecommunications for e-Health ITU-T SG 16 Question 28/16: Multimedia Framework for e-Health Applications ITU-T SG 17 Question 9/17: Telebiometrics These Study Group Questions bring together ITU diverse members (government, industry, academics, other stakeholders) to lead the work (studies, recommendations, best practices) on diverse aspects of e-Health The Question 14 assists in raising awareness of decision-makers, telecommunication operators and donors on the role of ICTs in supporting health-care in developing countries Participants in the Question share information on technical solutions and successful initiatives on e-health The main goal of the study is how to assist developing countries in the introduction of Telemedicine/eHealth services and solutions, covering the technical part. This is the unique international study group in the ITU-D SG2, Q14 dealing with needs of developing countries. Many organizations are developing standards related to diverse e-health fields, yet there is still a need to harmonize and coordinate these efforts Within ITU-T, Study Group 16 leads the work on multimedia terminals, systems and ubiquitous applications, such as e-health and e-business The increasing use of biometric authentication for identification is creating new challenges regarding security, safety, and privacy protection ITU-T’s Study Group 17 (Question 9) leads the work on telebiometrics, aiming to study and develop requirements for appropriate generic protocols for “manipulating biometric data”  33

Cooperation : SG2/Q14-2/2 m-Health support Goal: Promote the coordinated introduction of cost-effective mHealth applications in developing countries ITU Study Group 2, Q14 is discussing with members of industry and Research organizations to assit developing countries introducing mHealth solutions: Mobile phones can be integrated into a computer system to create an integrated health care information system mHealth technology for rural areas can also include mobile healthcare units Provide tailored support to developing countries to transfer knowledge, build local capacities, implement feasibility studies and support elaboration of project proposals to deploy large-scale, simple and cost-effective mobile solutions for Health On request of the ITU Member States attending meetings of ITU-D Study Group 2, this Initiative was recently launched. Two focus groups were set up within the Study Question 14 on Telecommunication for eHealth. Developing countries have a better penetration of mobile telephones vs land lines The mobile network allows reliable connectivity in remote areas Primary medical care delivery systems in villages and remote areas is relatively poor across all developing countries Primarily due to shortage in trained doctors Shortage in infrastructure and trained medical personnel The introduction of cost-effective and interoperable ICT applications in health care is essential to foster the implementation of e-Health initiatives in developing countries The spread of mobile cellular services and technologies has made great strides towards connecting the previously unconnected. By the end of 2007, developing countries had reached a rate of 49.8 mobile cellular subscriptions per 100 inhabitants.   Despite high growth rates and all high penetration rates in developing economies, major differences between developed and developing economies remain. At the end of 2007 developed countries had 100.3 mobile cellular subscriptions per 100 inhabitants. In absolute terms, the share/importance of developing economies in terms of mobile cellular subscriptions has greatly increased. By the end of 2007, 64 per cent of the world’s mobile subscriptions were from developing countries. Five years earlier, in 2002, they represented only 44 per cent. Amongst the developing regions, Africa continues to have the highest mobile growth rate (32 per cent in 2006/2007) and mobile penetration has risen from just one in 50 people at the beginning of this century to over one fourth of the population today (28 per cent). Note: These figures reflect the number of subscriptions, which is different from actual number of subscribers, as one user/subscriber might have several subscriptions, resulting in double counting of subscribers. 34

Cooperation :SG2/Q14-2/2 m-Health support Portable eHealth terminals Mobile Health Information Services Mobile clinics & Portable eHealth terminals Health Education (Health awareness campaigns, tips, quizzes, games, etc.) Health Data gathering (surveys, disease surveillance, research trials, etc.) Training for Health Workers Remote Patient Management & Monitoring (helpline, alerts, reminders, access to patient record, history, medication plan, tracking, Remote sensors, etc.) Dignostics and Treatment Decision Support Systems (2 ways SMS, , DSS software) Telemedicine services in remote areas (Telediagnostics, Teleconsultations, Telecare, etc.) There are two solutions: Mobile phone can be used for management and consultations related to medical services. Mobile eHealth care clinics/units traveling in rural areas from one village to another and connected to nearby hospital by wireless communication for consultations. Medical professionals : Second opinion to doctors on primary diagnosis Enable trained medical personnel (nurse) to provide quality primary care to patients Reduce errors in diagnosis across the healthcare delivery system Patients : Access quality medical information on mobile application Get diagnosis from signs and symptoms Understand their diseases and conditions better Act as a 24x7 medical advice system and management of medical emergencies Emergency Telemedicine services 35 35

Remaining Challenges Need for improved evidence of the economic and social benefits of e-Health Problems achieving interoperable e-Health applications and standardization Many pilots for e-Health projects exist, but scalability is an issue Improved communication between telecom and health sectors eHealth could make a huge contribution to maternal and child health and even immunization; but the message has not been accepted so far. 36

Conclusions (1) The telecommunication and health care sectors have to work together in developing national e-Health strategies Successful e-Health services require commitment to promote national strategies and facilitate capacity building Developing countries urgently need a strategic document – eHealth Master Plan and a Roadmap The telecommunication and health care sectors have to work together in developing national e-Health strategies Successful e-Health services require more than just technology: Committed policymakers who promote national strategies and facilitate capacity building are essential for the e-Health system to work in practice. Developing countries can not speed up the implementation of badly needed eHealth services without close cooperation with telecom sector. Developing countries urgently need a strategic document – eHealth Master Plan ITU-D is ready to assist its Member State in strengthening their in e-Health capacity to increase the impact and effectiveness of their investment in this field.

Conclusion 2 Effective governance of eHealth requires codes, regulations, and standards to ensure satisfactions of the consumers. Issues include legal liability, ethical standards, privacy protection, and cultural and social standards.

Additional Resources ITU statistical database of ICT indicators per country and region (www.itu.int/ITU-D/ict/index.html) Expert aid in drafting and implementing national e-Health projects (www.itu.int/ITU-D/projects/index.html) Training opportunities (www.itu.int/ITU-D/hrd/tc/index.asp) Policy and regulatory reports and symposia (www.itu.int/ITU-D/treg/index.html) Regional office in Addis Ababa to support Member States in Africa (www.itu.int/ITU-D/afr/CMS/index.asp) eHealth could make a huge contribution to maternal and child health and even immunization; but the message has not been accepted so far. 39

Thank You! For more information on ITU’s e-Health Activities visit the website at: www.itu.int/ITU-D/cyb/app/e-health.html 40