1. WHO eHealth initiatives: addressing
priority challenges in health systems
S. Yunkap Kwankam
Coordinator eHealth
World Health Organization, Geneva
eHealth Med-e-Tel 2008 Luxembourg

2. Outline of presentation
The WHO six point agenda
Priority challenges in health systems
The Africa Health Infoway
The RF global initiative on eHealth
Conclusion
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3. WHO has a six point agenda for addressing gaps
and improving public health
Goal Description
Accelerate Bring to life-saving and health-promoting interventions to the poorest of
1 development the poor
Fundamental
health needs
Foster health Improve health security for all especially as it relates to emerging and
2 security epidemic-prone diseases
Strengthen health Focus on capacity building, financing, systems for collecting vital
3 systems statistics, and access to appropriate technology including drugs
Strategic
needs Harness research, Generate authoritative health info, define standards, articulate evidence-
4 info & evidence based policy options & monitor evolving global heath situation
Enhance Build partnerships with UN agencies and other international
5 partnerships organizations, donors, civil society and the private sector
Operational
approaches Improve Continually improve effectiveness of WHO initiatives and staff
6 performance
Overall effectiveness of effort measured by impact on
women’s health and health in Africa
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4. Health systems in Africa are especially weak
Births attended by skilled health personnel1 One-year-olds immunized with DTP32
% 93.3
%
93.4 93.8 88.0
100 80.9 83.5 100 83.3
80 80 68.2 66.1
58.0
60 46.5 50.9
60
40 40
20 20
0 0
AFRO AMRO EMRO EURO SEARO WPRO AFRO AMRO EMRO EURO SEARO WPRO
Infant mortality rate3 Maternal mortality ratio4
Deaths per 1K live births Deaths per 100K live births
93.9
100 1000 865.4
80 60.1 800
60 50.0 600 447.6
396.4
40 21.2 400
17.5 12.4 119.6
20 200 33.8 67.8
0 0
AFRO AMRO EMRO EURO SEARO WPRO AFRO AMRO EMRO EURO SEARO WPRO
More so than any other region, Africa needs to invest in its
health systems
eHealth Med-e-Tel 2008 Luxembourg
1. Latest year data between 1998-2006 2. Latest year data between 2004-2005 3. Latest year data 2004 4. Latest year data 2005
Source: WHO Core Health Indicators Database

5. As threats to global public health mount, stronger country-
and district-level surveillance and reporting needed
Threats to global public health security:
• Smallpox Selected emerging and re-emerging infectious diseases: 1996–2004
• Poliomyelitis caused by a wild-type
poliovirus
• Human influenza caused by a new
virus subtype (e.g. avian flu)
• SARS
Diseases of documented, but not
inevitable, international impact, e.g.:
• Cholera
• Pneumonic plague
• Yellow fever
• Viral haemorrhagic fevers (Ebola,
Lassa and Marburg)
• West Nile fever
Drug resistance in existing threats:
• Tuberculosis
• Diarrhoeal diseases
• Hospital-acquired infections
• Malaria
• Meningitis
• Respiratory tract infections
• Sexually transmitted infections
• HIV/AIDS
eHealth
Source: WHO World Health Report 2007 Med-e-Tel 2008 Luxembourg

6. Other infectious disease outbreaks have incurred massive
economic costs to countries
This economic cost is particularly difficult for poorer
countries to bear
eHealth Med-e-Tel 2008 Luxembourg

7. In the past, weak health systems have failed to stem
rapid emergence and spread of disease
Example: Failure to detect and curb spread of HIV/AIDS early on has led to massive human and financial costs
eHealth
Source: WHO World Health Report 2007 Med-e-Tel 2008 Luxembourg

8. Sub-Saharan Africa
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9. Focus of health investment should be on improving sector
productivity, cannot just increase funding
Level of HC spending is a function of Healthcare is an inefficient sector, can
GDP/capita regardless of external funding improve productivity through technology
10000 Baumol's cost disease: Labor intensive
R2 = 0.94 services, such as health care, face
Health spend per capita (2005)
productivity lag - cannot substitute capital
for labor as efficiently as the general
1000
economy, so the cost of producing them
goes up faster than general inflation
100
5 ways to improve productivity:
1) Increase capital per worker
10
2) Improved technology
100 1000 10000 100000
3) Increased labor skill
GDP PPP per capita (2005) 4) Better management
Source: Nicholas C. Petris Center on Health Care Markets &
Consumer Welfare (UC Berkeley), WHO, A Handbook of Cultural
5) Economies of scale as output rises
Economics (James Heilbrun)
The most effective way to improve productivity is to
improve health systems
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10. Effectiveness of health spending widely variable
Health outcomes not tightly linked to income level
Log GDP/Capita (PPP) vs Childhood (<5) Mortality
300
Childhood (<5) Mortality (per 1000)
250
200 Rwanda
Cote d'Ivoire
Countries with similar profiles with
150 very different health outcomes
Togo
Kenya
100
R2 = 0.60
50
0
100 1000 10000 100000
GDP PPP per capita (2005)
Variation in health outcomes highlights considerable room for
improvement of inefficient and ineffective health systems
Source: WHO
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11. Countries with a critical shortage of health service
providers (doctors, nurses and midwives)
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12. Distribution of health workers by level of health
expenditure and burden of disease, by WHO region
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13. Challenges of scaling the health workforce in
Africa
Assuming 20 years to scale up workforce
Need to train 2.8 million (140 thousand/year)
77 thousand trained/country
3,800 workers per year for 20 years
10 workers per day!
Current estimates of training output for Africa range from 10% to
30% of what's needed
Costs of scale-up – training and salaries – adds about $10/capita
minimum to health spending by year 2025.
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14. Africa Health Infoway is a vital part of WHO’s eHealth
effort
The Africa Health Infoway (AHI) is
district-based public health information
network for African health
It is an investment in health systems to:
– support the collection of sub national
health data and statistics for analysis,
dissemination and use to support
decision making in Health
– strengthen capacity of African countries
to use information in decision making
This will include:
– data for epidemiological research
– indicators for monitoring and evaluation
– financial and cost reporting for clinic
management
– drug, equipment, supply stock reporting
for supply management
eHealth Med-e-Tel 2008 Luxembourg

15. Interoperable HIS in countries with data communicated and
merged across several dimensions
Across district mediated initiatives Across geographies
Surveys
Registration Registration
• Homes
and and
• Facility
census census
• District
Disease Health
surveillance service Across programs
statistics
Census Malaria
TB HIV/AIDS
Across points of care Across technologies
Hospital
Health clinic Community
health
worker
eHealth Med-e-Tel 2008 Luxembourg

16. 2
eLearning easing healthcare HR crisis in Kenya
eLearning can reach goal w/in next
In Kenya, chronic shortage of Promising progress since start of decade versus >200 years w/
highly skilled nurses program in Sep. 2005 traditional classroom methods
Enrolled Nurses (ENs) comprise eLearning vs. traditional methods
70% of nursing and 45% of the for upgrading ENs
health workforce in Kenya
• First point of contact for (K) 25
communities, but are 22,000 ENs to upgrade
inadequately skilled to manage
20
new and re-emerging diseases
like HIV/AIDS
15
PPP led by the Nursing Council of
As of Nov. 2006, 3,265 nurses • ~2,800 ENs
Kenya (NCK), the African Medical upgraded/yr
upgraded
and Research Foundation 10 • Cum. cost ~ $2.5M
(AMREF) and Accenture to • ~$114/nurse •~100 ENs
27 colleges and schools
upgrade 22,000 ENs from upgraded/yr
participating including AMREF’s •Cum. cost ~ $50M
‘enrolled’ to ‘registered’ level 5
Virtual Nursing School •~$2,273/nurse
within 5 years via eLearning
(distance education through ICT)
Over 100 computer-equipped
methods 0
training centers set up in 8
05
07
09
11
13
15
25
provinces, including remote and
20
20
20
20
20
20
22
marginalized districts
eLearning
Traditional classroom method
Results do not just represent dramatic cost and time improvements
over status quo, they are nearly impossible without use of ICT
eHealth
Source: Source: WHO, AMREF website Med-e-Tel 2008 Luxembourg

17. 3
“On Cue” SMS reminders for TB patients in South Africa
illustrates potential improvement in compliance...
“On Cue”: 2002 project in South Africa
sending SMS reminders to TB patients for Potential impact of SMS reminders for TB patients
drug regimen compliance
% 100 Assuming 99%
Evidence suggested that TB patients often Died 7.4 compliance 7.4
rate with SMS
do not take their medication simply 90 Unable to be Do not have
10.6 reminders 10.6
because they forget evaluated cell phones
80 3.1 3.1
Most widely used treatment method Non-compliant 10.8 7.7 7.7
Directly Observed Treatment, Short-course 70
Have cell
(DOTS), involved direct observation of phones
patient taking medicine to ensure 60
compliance – an HR-intensive method that
is still not 100% successful 50
On Cue Compliance Service designed to 40 78.9
improve compliance at lower cost: 71.2
Compliant
database of 138 patients taken at pilot 30
clinic, SMS messages sent out every half
hour to remind patients to take medicine 20
As of Jan. 2003, the city of Cape Town 10
paid $16/patient/yr for SMS reminders
0
In pilot, only 1 patient out of 138 was DOTS Treatment Non-compliant Non-compliant DOTS treatment
non-compliant (99.3% compliance rate) Outcomes patients with cell "converted" to outcomes with
phones compliant with SMS reminders
SMS
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Status quo
Source: Bridges.org, WHOSIS, WHO Global Tuberculosis Control report
Potential impact

18. 3
...which could result in significant TB mortality
reduction over time in South Africa
Cost is low, cost-
One benefit: Potentially significant TB mortality reduction effectiveness ratio favorable
# people
50% of untreated
• ~242,000 DOTS patients/year
12,000 patients eventually
10,673
die from TB • ~$16 per patient per year for
10,000 SMS messages
72% of South 99% compliance
8,000 Africans have rate with SMS
cell phones
• Country cost of ~$3.9M per
reminders in pilot
5,337
year for South Africa
6,000
3,842 3,804 • This equates to ~$1000 per
4,000
death averted
2,000
• One TB death equates to ~20
0 DALYs
Non-compliant DOTS Deaths due to non- Patient cell phone Deaths averted
patients compliance coverage
• Thus, cost-effectiveness
In steady state, this represents an 11% decrease in annual ratio of the intervention,
mortality due to TB in South Africa (currently ~34,000/year) without considering other
benefits, is ~$50/DALY
Other benefits include increased efficiency due to lower cost of treatment, reduced
morbidity and building of capacity and infrastructure for other SMS-based interventions
eHealth Med-e-Tel 2008 Luxembourg
Source: Bridges.org, WHOSIS, WHO Global Tuberculosis Control report, Disease Control Priorities Project, Journal of Epidemiology and Community Health

19. 4
MMRS improving healthcare personnel capacity
in Kenya...
Mosoriot Medical Record System (MMRS), In resource-constrained Kenya, these
electronic HIV/AIDS medical records for rural improvements could translate to dramatic
clinics in Kenya, improved clinical operations benefits for HR capacity
Improved time efficiency of clinical care
• Patient visit time reduced by 22% Physicians and Nurses per 1,000
• Patient waiting time reduced by 38% 12
Nurses
11.2
• Provider-patient time reduced by 58% 10
Physicians
Potential total with eHealth
• Clinical personnel-patient time reduced by 50%
• Clinical personnel interactions with each other 8
reduced by 66%
6
Monthly reports for the Kenyan MoH, which 4.5
previously took 2 weeks to prepare are now 4 3.1
2.6
2.6
routinely prepared in an hour 1.5
2 1.3
• MoH now ranks Mosoriot center first among all
Kenyan health centers in terms of speed, 0
accuracy and completeness of monthly reports Kenya Low Lower mid Upper mid High
income income income income
Lower cost of administration relative to other
programs Assuming similar results at all other healthcare
• Cost per MMRS HIV/AIDS patient = $250/yr facilities in Kenya, transitioning from paper to
• Cost per PEPFAR HIV/AIDS patient = $1500/yr electronic medical records could effectively
double healthcare HR capacity
eHealth Med-e-Tel 2008 Luxembourg
Source: Informatics in Primary Care (2005), Journal of the American Medical Informatics Association (2003), WHO, interview with Bill Tierney

20. 4
...and allowing transformation to evidence-based
management of health
MMRS EHR data allowed for Kenya lags others in vital Kenyan vaccine coverage
proactive care delivery childhood immunizations has declined and stagnated
Two patterns of care noticed DTP3 vaccine coverage (2005)
Historical vaccine coverage, Kenya
% 100
on MMRS reports: 90
80
70 88 93 92 % 100
60 69 75
50 90
• Cluster of STDs in one
Kenya Low Lower Upper High 80
village team of nurses middle middle ?
70
dispatched to investigate Income level averages
60
• Team was able to Measles vaccine coverage (2005)
% 100 50
identify and treat 90
80 40
individual that was 70
60 76 76
88 92 95
30
responsible for 50
Kenya Low Lower Upper High 20
spreading disease middle middle DTP3
10 Measles
Income level averages HepB3
0
• Lack of child HepB3 vaccine coverage (2005)
84
87
90
93
96
99
02
05
immunizations in another % 100
19
19
19
20
19
19
19
20
90
80
village nurses 70 85 94 90
76 79
dispatched to village, 60 60
50
Potential for EHR system to
children immunized for
Potential Kenya Low Lower Upper High catalyze increase in vital
broader middle middle
childhood immunizations
Income level averages
implications
MMRS has since been expanded to an open source EMR platform, OpenMRS
eHealth Med-e-Tel 2008 Luxembourg
Source: Informatics in Primary Care (2005), Journal of the American Medical Informatics Association (2003), WHO, interview with Bill Tierney

21. Sharing eHealth IP4D (SHIPD)
Healthcare in the developing world
Vision is improved by sharing eHealth
Intellectual Property SHIPD phase 1 in 6
countries
Cameroon
Kenya
Nigeria
Tanzania
Uganda
Zambia
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22. Disease surveillance: early detection and response of
emerging diseases can prevent potential epidemic
spread...
A general model for disease emergence and spread
eHealth
Source: WHO World Health Report 2007 Med-e-Tel 2008 Luxembourg

23. The RF eHealth global initiative
Develop and promote a global eHealth
agenda - strategies to address common
policy, organizational, technical, legal,
financing and sustainability challenges
identified through conference track and
keynote sessions;
Promote the importance of
interoperability and open, standards-
based platforms to donors, countries and
technology companies
Catalyze the formation of new
collaborations around thematic areas and
explore establishment of national
Summer Bellagio series platforms and a self-sustaining global
July 14-Aug 8, 2008 eHealth coalition.
eHealth Med-e-Tel 2008 Luxembourg

24. Conclusion
Promoting a global vision and local insights
Human resources are key
People processes and technology
Partnerships are the model
AHI - Global Health Infoway
Major opportunities for ISfTeH and IMIA
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25. THANK YOU
kwankmy@who.int
eHealth Med-e-Tel 2008 Luxembourg