Reading report week 9 Part1,2: Natasha Ikhsan (M1)
Integration of ICT to health systems in underdeveloped rural areas
The following discussion is based on World Development Report 2016: Digital Dividends page 190-192.
Background
In countries where majority of population live in rural areas which are still remote, and hard-to-reach, the provision of rural health care systems is still a big challenge. For instance, more than 80% of Ethiopian population reside in rural areas and more than 30% of them considered as poor. Even though since 2003 the Ethiopian government had trained and employed more than 40,000 Health Extension Workers (HEWs) to serve rural areas, due to lack of capacity and often HEWs are isolated, they could hardly prioritize urgent and unpredictable health cases such as pre- and post-natal care.
What is the solution to this challenge?
To address this problem, the World Bank, African Development Bank, and Addis Ababa University developed a better communication system between HEWs and patients with the renowned platform called ‘FrontlineSMS’ aimed to improve information flows (Atnafu et al., 2017). With the FrontlineSMS, communication between HEWs and patients were made simpler and more convenient. For instance, HEWs can register pregnant women and newborns and automatically send short text massaged (SMS) as reminders of appointments or to track the stock of essential medicines. This system works only with existing mobile networks and low-cost cell phones.
If simple mobile networks can do a lot to improve rural health care in Ethiopia, introduction of internet would make much more improvements in places with internet connections. From mobile-based health care (m-health) that is useful for bridging connections between patient and health workers, the internet can expand the system to broader Health Management Information Systems (HMIS) that can potentially cover integrated telemedicine, online-based consultations, electronic medical records, etc. that can be accessed by both patients and health workers regardless their locations as long as they have internet connection. This is the future of health system that is called e-health.
Benefits
One of the most apparent benefits of m-health and e-health is the efficiency improvement in health care systems. System efficiency can be improved as countries can use cloud computing and connect remote patients with health workers or remote health workers with clinical staff community so they can make better diagnoses and treatment decisions at lower costs and shorter time. In addition to cost and time savings, the substitution of paper-based administration with electronic ones could help improve administrative management and better inform management decision making. Besides, Information, Communication, and Technology (ICT) platforms such as social media, websites, and access to personal data in electronic health records could enhance accountability and transparency that encourage citizens to actively contribute in health care governance.
Potential issues
These advanced improvements on traditional health care systems demand for ICT-skilled health workers. Therefore, implementing countries need to conduct health informatics training program in order to prepare a qualified e-health workforce. Besides, according to World Health Organization (WHO), development of e-health has been slow. By 2011, 93 of 112 health care systems in surveyed countries had already adopted some form of m-health or e-health systems mostly for emergencies, telemedicine, and information systems. Inconsistencies in data management are also reported to occur frequently. Sometimes data are captured multiple times leading to double counting and inaccuracies. Often data are not captured at all. And too often data are captured in such a way that data can not be shared as needed. These problems emerged from interoperability issues or lack of health information exchange standards.
E-health during COVID-19 pandemics
As we discussed briefly about what e-health and m-health can bring to health care systems, ICT integration to health care system can really help to improve health care system in today’s world. COVID-19 has spread to almost every country in the world. Online-based data storage and management can help with the real-time updates of COVID-19 cases (number of infected and treated cases paired with the locations of patients). Without realizing it, we actually already witnessed the uses of e-health in COVID-19 handlings in many countries. However, not all countries are equipped with advanced ICT systems as we could see that many countries are not reporting their updates on the case. The disparity of ICT application still exists even in times when it is needed the most such as during this pandemic. Besides, the use of e-health during COVID-19 pandemic is still limited to data management and information. The ultimate goal of e-health which is to ease health care systems in rural underprivileged areas is still far off from reality.
Reference:
Atnafu, A., Otto, K., & Herbst, C. H. (2017). The role of mHealth intervention on maternal and child health service delivery: Findings from a randomized controlled field trial in rural Ethiopia. MHealth, 3, 39–39. https://doi.org/10.21037/mhealth.2017.08.04
World Development Report 2016: Digital Dividends page 190-192. https://www.worldbank.org/en/publication/wdr2016
Digital Identity (Digital ID)
The following discussion is based on World Development Report 2016: Digital Dividends page 194-197.
Everybody needs an identification mechanism to identify one another and more importantly to identify themselves to their community and governments as legal citizens. Being identified to a community or a country is profoundly important as it allows those identified individuals to have access to a range of rights and public services. Traditional formal identification systems involve physical tokens such as paper-based identification (ID) cards. However, there is enough evidence to prove that these traditional systems are failing in developing countries as almost 2.4 billion people are left unregistered. Those unregistered people are usually the poorest and the most marginalized members of society. As consequences, they have no access to basic services such as health care, education, and the like.
How can we make sure that everyone on this planet has legal identity hence access to their basic rights as a member of society? Many believe that the best way to achieve it is through digital identity (digital ID). Digital ID is a system when personal data is stored in digital form rather than physical.
Universal concept, yet varied roles
Despite the universal concept of digital ID, the scope of its purpose varies across the world depending on the country context. Fig. 1 shows the variations across countries. It seems that in high-income group, there is a higher proportion of countries that apply multipurpose digital ID than digital ID that is meant for identification purpose only. The distribution in developing group, by contrast, shows that only a few countries have multipurpose schemes. And overall, the most common digital ID schemes in the world are the ones with identification purpose and access to limited services such as voting, cash transfers or health.
Variations are also observed between high, middle, and low-income countries when it comes to the extent of improvement digital ID can bring to a country. In high-income countries, the replacement of physical ID systems to digital ID can be seen as an upgrade from already-well-established traditional systems. This can only lead to efficiency improvements on public service delivery and also improvements for the citizens to access public services more conveniently. On the other hand, in low-income countries lack of robust civil registration systems, even in the case of traditional physical ID, the transitioning to digital-based systems look more like leapfrogging instead of an upgrade. Without solid registration systems, shifting to digital ID may cause a significant proportion population especially those that age 0-18 left unregistered. In middle-income countries, the transition to digital-based systems take place progressively and support the emergence of various e-services.
Does digital ID really have positive impacts?
There are at least three key areas that have been improved according to success stories from all over the world:
- Management of social welfare programs
A success story from India’s fuel subsidy program can be one of examples for this area. For fuel subsidy distribution in India, having bank accounts linked to individual digital IDs allows targeted cash transfer to perform more accurately and efficiently. The Indian government also benefited from cost-savings through reduced leakage to “ghost” or duplicate beneficiaries and from the improved efficiency.
- Elimination of “ghost” beneficiaries from payrolls
The implementation of digital ID system for civil servant in Nigeria successfully removed about 62,000 “ghost” workers from payrolls and consequently saved US$ 1 billion annually.
- Improvements on election integrity
Another story from Nigeria, but this time, digital ID was deployed in Nigeria’s 2015 election. The upgrade from paper-based voter cards to biometrics-encoded ones enable the officials to prevent duplicate votes as voters were needed to do fingerprint authentications before taking votes.
Functional vs. fundamental schemes
In some cases, digital ID might be emerged in response to specific application such as elections, tax, health insurance, etc. These systems are called functional schemes. On the other hand, the systems may be developed as universal multipurpose systems that provide legal identity for all possible applications. These are known as foundational identity schemes. Often times, functional ones gradually advance into foundational.
Potential risks
Based on collective experience of digital ID systems across the globe, there are several areas of concerns identified.
- Legal and regulatory concerns
This concern refers to the question of what regulations need to be applied to prevent undesirable outcomes such as mandates that could deter individuals from getting access to public services. New regulations are also needed to clarify the types, extent, and use of information. Besides, how to safeguard privacy of personal data is also a big concern.
- Institutional and administrative concerns
This concern has a lot to do with the question about which governmental institutions or ministries have legal roles to do the digitalization. Effective coordination across institutions is of a great importance to prevent competing schemes or inconsistencies. This risk is higher for functional schemes as many institutions might have different digital ID systems for different programs.
- Technological concerns
One of the challenges is how to develop a sustainable digital infrastructure that could reach not only urban areas but also remote areas. This system must also ensure data security and robust authentication protocols.
- Country-specific and cross-border concerns
As the world has advanced to define standards for the universal recognition of foreign citizens. This may enable the abuse of the system for example ethnic group tracking or other unethical purposes.
- Business models and procurement concerns
This concern stems from the lack of standards on costing guidance and the absence of viable business models.