This course proposes an overview of current global health challenges drawing on the insights of several academic disciplines including medicine, public health, law, economics, social sciences and humanities. This interdisciplinary approach will guide the student into seven critical topics in global health.
Information and Communication Technologies for Global Health by Antoine Geissbuhler
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Do curso por University of Geneva
Saúde Global: Uma Visão Interdisciplinar
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Research, Development, Innovation and Technology for Global Health
This module addresses the lack of attention to research and development for medicines and technologies for diseases that disproportionately affect developing countries and all the issues related to drug development and intellectual property rights.
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Rafael Ruiz De CastañedaInstitute of Global Health - Faculty of Medicine
University of Geneva
Antoine FlahaultProfessor of Public Health and Director of the Institute of Global Health (Faculty of Medicine, University of Geneva) and co-Director of Centre Virchow-Villermé (Université Paris Descartes)
University of Geneva and Université Paris Descartes – Sorbonne Paris Cité
[MUSIC]
Ladies and gentlemen, this session is about information and
communication technologies for global health.
We will be discussing telemedicine, eHealth, and mHealth, which
are fields of application of communication and information technologies in health.
Obviously, communication technologies have been used for
a long time in health and healthcare.
We can trace back,
for instance, the use of the telegraph during the American Civil War
back in 1861 to organize medical rescue on the battlefields.
We can also cite as an example the fact that the first
electrocardiogram was transmitted via telephone back in 1906.
So, this is not new.
But what is new is obviously the scope, the large number of applications,
and the fact that those technologies are now part of information society and
therefore affecting a lot of the sectors that are connected
to global health and obviously healthcare in particular.
So, if we look at the key concepts we're going to be looking at today,
the first one is telemedicine.
And telemedicine has many possible definitions, but if you really look at
the conceptual level, it is about moving expertise rather than moving people.
It is avoiding to transfer a patient because he can get
an advice from a remote specialist.
It is avoiding to have to move a care professional because you can
exchange enough information to solve a healthcare situation.
So, it is mostly about remote support for managing patients,
whether directly connecting a care professional to a patient or connecting
a care professional to another care professional in order to manage a patient.
Actually, in our thinking, we are also extending this idea of
telemedicine to capacity building or to in-service education,
like continuing medical education over a distance.
And the idea here is to consider that the field of
healthcare is changing rapidly in many ways and
that being educated, being recycled in terms of knowledge and
ability to apply this knowledge is an integral part
of maintaining and developing the health system.
I think it's worthwhile reminding the fact that according to WHO estimates,
there is a critical shortage of more than 1 million healthcare agents,
in particular in Sub-Saharan Africa and Southeast Asia.
And this shortage is preventing the development of a functioning health system
in many of these countries.
So, the ability to improve capacity, either initially but
also once care professionals are active is something essential.
And it's clear that doing that over a distance, using information and
communication technologies can play a significant role.
The second aspect is what we call eHealth.
And again, there are many definitions,
but the basic concept is about connecting stakeholders.
The distance is not an issue as it is in telemedicine.
It's really about connection and
making sure that the information will flow between stakeholders, either for
healthcare, but also for public health or for preventative medicine.
And it is about improving the continuity of care,
efficiency, quality, or safety of services.
And finally, one of the subdomains of eHealth is what we call mHealth for
mobile health.
And this is really about eHealth but using the mobile connectivity.
And as you know, mobile telephony has been revolutionizing
many aspects of society and
is actually becoming the primary way for accessing the Internet in many countries.
And so, the ability to use those mobile technologies meaningfully
in the field of health and healthcare is becoming very promising.
The other thing that's quite interesting with mobile phones is that it
is a mostly personal item, or if it's not personal, to a smaller community,
and it's connecting this person to the digital world.
So, it's a digital proxy to the digital world, and therefore,
a mechanism by which a person can interact both ways with the digital world.
Now, we are not going to be surveying all the project that exists in this field.
We are going just to take some illustrations,
just to show what are the potential, but also the challenges, and
maybe tools, to mitigate those challenges, or to overcome those challenges in
the field of information and communication technology for global health.
For telemedicine, we're going to look a bit more in detail to
a project that we've been involved with here in Geneva about
de-isolating care professionals using continuing education and tele-expertise.
Now, if we were to look at projects in eHealth, there are many but
most of them are about how do we improve the management of information for
healthcare services delivery and public health.
And the key tools that are going to be used in eHealth
are electronic medical records or they could be patient records.
And also aggregated views of information,
such as district health information systems.
And what we're seeing now is actually a convergence of those systems.
So, systems that are involved in the clinical processes,
connecting to systems that are used for public health and
for managing health serviices.
And then mHealth is obviously a domain of a lot of innovation
due to the widespread availability of those tools.
And the idea that it is a personal tool, this is a tool that can be used for
instance for influencing behaviors of patients, citizens, or care professionals.
And also for empowering patients who have their own tool to access and
manage information so that they can use those tools to access online information.
Or, for instance, to try to detect counterfeit drugs using mobile
phones in which you type some numbers that you find on the packages and
some external system can verify that those numbers match a known identity.
And therefore increase the likelihood that you're going to be buying non-counterfeit
drugs, which as you know, in many countries in the developing world,
is a significant issue.
It can also be used to send reminders for making sure that patients will
continue taking a treatment for long-term treatments or for
treatments that are quite sensitive, such as treatments for tuberculosis.
Or reminders during pregnancy to make sure that the pregnant
woman will be aware of what needs to be done at which stage of pregnancy or
give advice, or actually enable the pregnant woman
to seek advice when facing an unusual condition.
So let's look at this project that really aims at
de-isolation of care professionals.
And here on the slide, an example often isolated care setting.
You meet here on the right side of the slide Dr. Diak,
who is the first physician who actually accepted to work for
more than a few months in this remote hospital in Mali.
And one of the reasons why
his predecessors didn't stay very long was the isolation.
800 kilometers away from the capital, more than 100 kilometers away,
which means a few hours of traveling to get to the first internet access.
And actually, tens of kilometers away from the first telephone Access, so
it's a remote setting, but
it's also the only hospital available for
a population of more than 30,000 inhabitants.
And so,
this was used as one of our labs to try to understand what was the potential
of bringing Internet connectivity and services, to a care professional.
And as you can see, this is not very fancy.
It's actually a satellite connection.
But the whole system is solar powered, and
the physician has access through a laptop and a web cam to the internet.
And with those connections can follow courses,
weekly distance education courses.
Which means that this physician's connected to his peers,
connected to the specialists in the field.
Can request advice when it's faced with a difficult case,
it can take a picture of the patient, it can take electro cardiograph tracing and
send these to the cardiologist that he knows in the capital, and
will look at the case, discuss the case, and help manage the case.
I'm actually Dr. Diak even perhaps the university.
Using e learning at the university of in France.
We've learned a lot of things with this laboratory setting.
One of things we've learned is it's very difficult to sustain economically.
A satellite connection in such a remote setting.
And actually, this project has now moved to focus much more on district-level
hospitals, which are hospitals that deal with a population of around 100,000 or
150,000, and where you can have enough services, enough usage, but
also enough resources that telemedicine can make a difference.
One of the things we've experimented is what we call task shifting.
It's basically enabling care professionals to do things that usually
were done by others.
And a good example is echography.
Ultrasonography.
Basically, within a week we can train a general practitioner,
we can train a midwife to the appropriate views of a portable echograph.
It doesn't make them specialists in radiology or in gynaecology but
enough skills so that they can produce reliable images.
And those images can actually be shared with a radiologist.
Which will, obviously, stay in the capitol.
But review those images in the clinical context of the patient and then
give advise in terms of the interpretation and the potential diagnosis.
You don't need to make a very specific diagnosis.
What you need to do is make decisions at the appropriate, actual level of care.
And one of the key questions that you would ask at the district level is
can I manage the patient locally or do I need to evacuate the patient.
And if you can grant a few evacuations which are costly,
which might be dangerous then.
You increase the services you give to the population,
you increase the reputation you give to your hospital, and what we've measured
is that you increase the usage of those facilities that are typically underused,
whereas the central facilities in the capitals are typically overused.
So this task shifting, I think is a very interesting and
promising way of meaningfully using those technologies to actually
improve the services there to provide an access to the services in the rural areas.
One of the other things we've learned is the importance of
South-South collaboration,
exemplified here by a radiologist from Mali training care professionals in
as part of the development of a national program for telemedicine in.
What we've learned is that even if you remove distances
you don't remove the other socio-economical determinants, and
if you want to be credible, if you want to make sure that the advice you give makes
sense, then you need to have some proximity, some real understanding
of the situation that you will encounter in a district-level hospital.
And so, 80% of the activity, whether it's Capacity building through continued
education or whether it is still expertise basically giving
access to experts is down in a South-South collaboration and
80% of these activities stays within the country or within the region.
And finally one of the key lessons we've learned is if you want to
make sure that what you build and what you grow makes sense and
can last in a sustainable way,
you need to build expert capacity in some centers of excellence.
And this is something that we've started several years ago.
This is a long term project because you need to get motivated care
professionals to a level where they become academics in the field and
therefore can start their own research project, their own research agenda.
Can leverage their own research funds and then train a bit on trainees.
And then you have a sustainable environment,
where you keep progression, you keep learning.
But you learn also based on the real needs.
And that's something that we believe is very important.
We have first Mali.
We're building another one in [INAUDIBLE], Cameroon.
And hopefully, we will have four or
five that cover most of the areas were reactive in Africa.
So what are the challenges of deploying those tools and there are many challenges.
One of them is a new disease we call that pilotitis and
it is really the disease of having to many pilot's of having projects that
are each very nice, very promising that seem to work very nicely.
But that are unable to scale.
And this is a significant problem,
especially in resource constraint countries,
where you cannot just make many projects side by side and make sure that.
And not consider the fact that they are not going to converge,
that they are not going to be integrated in some national strategy and
actually help really bring the whole health system to a higher level.
And this is due to a lot of the diseases we know from other domains of development.
But this is in particular in the field of medicine.
Due to lack of interoperability.
This means that you have systems that don't know how to talk to each other,
how to work with each other, and this is a major challenge.
The other big challenge and one of the reasons why decision makers
are reluctant to invest massively in those tools even though there
is a big hype and a big trend in trying to do that Is that we've been
very poor at demonstrating impact or even evaluating impact.
There is a lot of evaluation about usability of the technology,
feasibility of the technology but
whether this technology, once applied in a specific domain,
actually makes a difference, is something we've been very poor at demonstrating.
So there is a big need for
the community of health implementations of those involved in developing and
deploying those tools to actually measure impact, document the fact that there is
an actual added value and not just the promise of an added value.
Well, this requires capacity building usually of care professionals.
This is a new profession, and
actually there's a shortage of health implementation worldwide
as those systems are becoming more and more frequently deployed.
So there is a clear need for capacity building, but not only of professionals.
Also of the leadership.
The governance, the decision makers need to understand the pros and
cons of those tools if they want to make informed decisions and
decide that they need to allocate resources
in this domain rather than in others that are also priority domains.
And finally, and this is still a challenge even though everybody
believes that it's going to be solved next year.
Actually, for the last ten years we haven't seen that much progress in
Internet connectivity and in the quality of bandwidth outside of the main cities.
And outside of the main cities is where we think the impact is the greatest.
So we're still struggling to deploy those tools because
satellite connectivity is extremely expensive.
And the rest of the connectivity currently,
the market to move them outside of the main cities is too limited.
3G connectivity is coming.
Other forms of connectivity, including 4G is very promising,
but we're still struggling to get these happening.
And there are now efforts to deploy new constellation of satellite that might be
cheaper from which satellite that it also poses some issues regarding
sovereignty of countries, because then you depend on connectivity
that you cannot really control because it belongs to another state usually.
So what are the tools that we can use to improve those various aspects?
One is governance and I think the two eHealth resolutions that were passed
first in 2005 release of laying the ground of and understanding how eHealth should be
part of the tool set for developing health systems.
And more recently, a few months ago, there was another resolution passed on
standardization and interoperability showing what are the limits
of what is that's been done over the last ten years, and why it's important to
converge on standards, interoperability, and actually evaluation.
There are tools that are starting to emerge and
can be used to help strategic planning at a national level.
I will just mention the WHO-ITU National eHealth Strategy Toolkit,
which was released a few months ago and has been used by several
countries to try to develop their national eHealth strategy.
If you have a strategy,
it's easier then to make sure the whole system will converge.
Evaluation as I mentioned, we are poor at doing this, we need to have some tools.
What we are working on at this stage is databases of indicators that
could be reused by the different projects,
make sure that that is what is learned in these projects can be compared to others.
And also I build registries of the evaluation studies just like has been done
in clinical trials.
And finally as I mentioned earlier, we need to think sustainable and for
me the keywords are centers of excellence, the ability to have centers
where there is enough expertise that locally adapted but
international level of research can be done.
South-South collaboration, which is key to make sure that the solutions are actually
relevant, and reverse innovation,
which means this idea that you need to innovate close to where your problems are,
rather than innovate in the labs in the north and then try to plight in the south.
Innovate in the south, and then you learn bad things that can actually be used
more globally even in the north.
So this is, in a nutshell, some of the key opportunities, challenges and
tools that we're working on when we talk about telemedicine eHealth and
in-house for global health, thank you very much.
[MUSIC]
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