Document(s) 4 of 31

Introduction

The past decade has seen a remarkable growth in the diffusion of information and communication technology (ICT) across the world. This growth has been fuelled by technological advances, economic investment, and social and cultural changes that have facilitated the integration of ICT into everyday life. The general public – consumers – as well as a range of new stakeholders have had a significant impact on shaping this growth, for example by demanding better products, services and value for money. As these technologies enter the mainstream of business and cultural life, there is also a greater awareness of their potential as economic and social tools and, with it, new social and political pressure to re-frame ICT as a public good to be made accessible and available to all. This shift has had important ramifications in countries and at the international level as well.

Despite this encouraging progress, however, the uptake of ICT globally continues at an uneven pace, and the ‘digital divide’ remains a significant obstacle to achieving global development goals. The digital divide is understood broadly to be the gap between those with access to ICT and its benefits and those without. It is specifically acknowledged in the United Nations Millennium Development Goals (MDGs). Goal 8, Target 18 of the MDGs proposes ‘a global partnership for development to make available the benefits of new technologies, especially information and communication technologies’.¹

Recent events such as the G8 Summits and the World Summit on the Information Society² have continued to promote this target and to highlight the striking gaps in access to ICT worldwide. In some countries, both urban and rural regions remain isolated from the knowledge society: infrastructure is non-existent, costs for basic services are beyond average income levels and well-intentioned ICT pilot projects end without ever scaling-up. While this can be disastrous for national economies competing in a global environment, it is also a tragedy for the health sector, where ICT is essential to improve health and help alleviate inequalities.

ICT in the health sector

In the health sector, ICT is a cornerstone of efficient and effective services. In many countries, use of ICT within the sector continues to grow, and the Internet in particular is driving significant change. For example, in middle- and high-income countries, the Internet is dramatically changing the way in which consumers interact with health services, including access to health information and the ability to purchase pharmaceuticals and other health products. The Internet also plays a key role in expanding the reach of health services to remote areas. The spread of broadband networks and the development of new e-health applications, defined as the use of ICT for health, have a mutually stimulating effect on further developments. However, it is clear that, despite the numerous creative and sometimes quite costly efforts to improve the situation, access to these developments is not universal, and many countries do not benefit as they might from advances in ICT in health.

For policy makers committed to improving national health systems, working with ICT policy makers and participating in the national policy-making process is essential to ensure that national ICT policy, when implemented, will meet the interests of the health sector in the years to come.

Measuring the digital divide

It has only been within the past few years that meaningful measures of the digital divide have been developed. The potential choice of indicators is enormous and the continuing evolution of technology shortens the useful lifespan of established indicators, creating the need for their regular revision. However, whether measured by ICT diffusion, technology investment or other related measures, the digital divide is manifest within and between countries in a variety of ways.

The digital divide is evident in low-income countries, where technology is unaffordable for private enterprise as well as for individuals, and where government policies and regulations do not encourage or support ICT business development. It is evident in the contrast between urban and rural areas, where investment in basic ICT infrastructure and services is chronically inadequate. It is also evident in communities and households, where literacy rates, educational levels and incomes are low and where content imported from abroad does not suit local needs or transmit in local languages. Most of these aspects are captured by the ICT Diffusion Index,³ which takes into account the complex dimensions of access, connectivity and policy in countries. The index results in a composite score between 0 and 1, giving a picture of ICT status in general but not addressing ICT diffusion by sector. The link between ICT, health and development is clear in Figure 2.1, showing country ICT diffusion and mortality strata, by WHO region^.4,⁵

Following the World Summit on the Information Society in 2003 and 2005, many countries undertook the development of national strategies that aimed to increase the use of ICT. Such strategies sought to increase investment and stimulate innovation, particularly in small and medium enterprises in the private sector, and to improve efficiency and effectiveness in the public sector (e.g. in government and education). For both the public and private sectors, the use of ICT in health, or e-health, is considered to represent a key instrument for health care delivery and public health action,⁶ and a number of governments have supported specific investments and policy instruments towards this end.

Figure 2.1 ICT diffusion and mortality. (Stratum 1 = very high adult and very high child mortality; stratum 5 = low adult and low child mortality.)

In high- and low-income countries, e-health has already demonstrated its value, particularly in containing cross-border threats to health and safety. However despite the documented value of ICT in terms of improving quality, cost and access to health care, the picture globally remains mixed. In particular, the ability to plan and implement e-health on a large scale, while adapting it to local health problems, presents a huge challenge for countries and institutions.

Despite the difficulties, there have been major ICT investments, particularly in countries such as those in Eastern Europe. These economies are growing rapidly, and large-scale infrastructure investments supported by the European Union include ICT for health institutions and universities. In higher-income countries, there is spending in the areas of information systems, electronic health records, e-prescribing systems, diagnostic tools and medical imaging. In developing countries, ICT pilot projects are being funded by international donors, leading to uncoordinated deployment of ICT in health service delivery and incompatible systems at many levels. In addition, investments are being made in applications that support ‘vertical’ health programmes such as disease surveillance, management of drug supply, and planning and monitoring human resources for health.

Driving forces for ICT in health

Challenges in global public health

Despite significant progress in public health over the past 50 years, the fundamental conditions for health have not been achieved in many countries. Most of the burden of premature death and illness among the poor is due to problems for which solutions are known and prevention is possible, yet the health of populations in developing countries continues to be at risk. Today, the gap in health between the wealthy and the poor, both within and between countries, continues to grow.

The health divide is evident especially in low-income countries, which face a high burden of endemic and epidemic-prone infectious diseases, unacceptably high levels of child and maternal mortality, a continuing HIV/AIDS pandemic and the rapid spread of chronic conditions accelerated by poverty. In many countries, there is a deepening crisis in access to basic health services, linked to a shortage of essential health workers.7 In the face of these and numerous other challenges, governments are attempting to build and sustain their health systems.

Over the last decade, the need to develop and organize new ways of providing health services has been accompanied by major advances in ICT, enabling better support for health services and systems, and improving global awareness of health issues. These technologies hold great promise for the health sector in both low- and high-income countries, and some countries are realizing the benefits today. This is true not only for the delivery of health services, but also for health-related markets more generally. As the use of ICT grows, it is vital that the health sector participates in key international forums and helps to shape national policy to ensure that ICT improves outcomes for health, particularly for the most vulnerable populations.

Forces for change

In all countries, including developing countries, forces from health care and the ICT industry are spurring the growth of e-health. These forces include industry developments in wireless and satellite systems, the spread of broadband communications, better access to applications and services, and increasing digital processing power and storage capacity. This growth has led to significant regulatory change, advances in consumer protection, greater patient mobility, and new opportunities for trade and cross-border services in health.⁸ In the health sector, driving forces for adoption of ICT include such factors as government pressures to control costs, chronic and ever-increasing health work force shortages, greater expectations by consumers for higher quality and safer care, and changing models of health care delivery.

From the micro-level to the macro-level, from basic human genetics research to the provision of humanitarian aid and disaster relief to populations at risk, ICT supports the health sector in addressing a vast range of immediate and long-term challenges to human life and health, through the functions outlined in Table 2.1.

A number of these uses of ICT promise particular benefits for developing countries. For example, decreasing the isolation of the health community is seen as a major benefit, and is thus a driver for adoption. ICT is increasingly well integrated in educational settings in middle- and high-income countries, where communication, collaboration and access to information are at the core of research and teaching. Universities in the developing world need to connect on an equal footing with their counterparts. This access will play an important role in advancing locally relevant research, and will improve capacity by enabling participation in the peer-review process required for publishing and participation in research conferences.

Improved access to care is an important benefit of ICT, particularly for countries tackling the challenge of providing health care to people over a broad geographical area. One of the main drivers behind public investment in e-health systems is the expectation that ICT will improve access to services and reduce the inequities experienced by people in remote locations. This is a serious matter in countries that have chronic shortages of physicians, nurses and health technicians. The problem of shortages is often coupled with public concern over access and demographic shifts with concomitant major health resource implications, such as ageing populations and rapid population growth in native or aboriginal communities.⁹ In contexts such as these, the goal of access to health care has driven the adoption of ICT for remote diagnosis, monitoring and consultation.

Quality of care is another important driver for ICT adoption. Health service providers are not only attempting to deliver more effective care, they are also attempting to deliver care that is safe. Both goals require the use of ICT to measure, monitor and report on quality improvement initiatives, as well as the use of information systems – such as pharmaceutical ordering systems – that are proven to reduce errors.¹⁰ Developments such as e-prescription and computer-assisted imaging are part of this. With respect to technology-assisted care, it is critical to ensure that the care and information provided through e-health meet appropriate standards, relating to the quality of information transmitted as well as to the overall reliability of the system and the satisfaction of users, both professionals and patients.

To date, e-health has mainly been used to improve productivity in delivery systems focused on patients and hospitals. In the future, it can be expected that ICT will be used to facilitate personalized and home-centred care. To this end, there has been significant investment in research and development, such as in the European Union (EU) Framework Programmes, which have invested over 500 million euros in establishing a European health area, e-health conferences and an e-health action plan.¹¹

The concept of citizen-centred care has become the basis of programmes designed to empower consumers in part by improving the health information environment. Many observers expect that the Internet and the web will become the place to obtain health advice for citizens. In 2007, the worldwide Internet population was estimated at 15.8 users per 100 inhabitants, up from 5.3 users per 100 in 1999.⁴ Health is consistently among the most sought-after types of Internet information.¹² Some governments, worried that the volume and quality of health information on the Internet might pose a risk to citizens, have responded by creating or sponsoring health information portals. Others have provided guidelines for website quality and promoted consumer education as a protection against the growing problem of Internet fraud and spam.

Economy and efficiency of care is another important driver for the adoption of ICT in health. Key areas aimed at controlling costs over the long term include hospital information systems, regional networks, secure reimbursement and procurement systems, and patient ‘smart cards’ carrying personal medical data. The electronic health record is central to the ability to improve quality, access and economy of care. It is also fundamental to realizing the concept of an expanded, digitized health care network that enables more effective public health services.

Just as ICT is at the core of much of the improvement in national health systems, global health security is also critically dependent on ICT. Reliable and secure ICT systems enable tracking of diseases and monitoring of populations at risk, and provide the basis for global defence against bioterrorism as well as early response to natural and man-made disasters. For example, the best way to prevent international spread of diseases is by detecting public health risks early and mounting an effective response while the problem is still localized. Rapid reporting, enabled and validated through global electronic communication, was a critical factor in the containment of the SARS epidemic in 2003 and is a key aspect of preparedness for pandemics such as that anticipated with avian influenza. Fortunately, steady improvements in satellite technology, and particularly its more widespread use, have enabled a faster, more coordinated response globally and nationally to disease events and natural disasters.¹³

An overview of ICT policy

It is important for health policy makers to have an overview of the forces and policies that shape the availability and cost of ICT, and to understand potential points of influence. This will ensure that the health sector benefits from ICT to the greatest extent possible. Globally, the ICT policy picture is complex and changing, and is not easily governed by traditional forms of national and international public authority. Beyond this, the Internet in particular has given rise to new patterns of international cooperation. Whereas the technical management of the Internet is dominated by companies working in industry forums to devise private systems of rules, in parallel governments and firms are collaborating to devise shared rules on communications behaviour and global electronic commerce conducted over that infrastructure.¹⁴ This is not a trivial matter for the health sector, as decisions made in this unwieldy international system will have a direct effect on the future development of e-health, such as patient mobility and the viability of cross-border services in health.

Interested parties

In addition to governments, other major stakeholders in the ICT policy-making process include a wide range of organizations and firms, such as international organizations (e.g. the United Nations, the International Telecommunication Union and the World Trade Organization), consumer rights organizations (e.g. Consumers International), regional Internet registries, private businesses (e.g. ICT systems and equipment vendors, telecommunications operators, Internet service providers, and financial and certification companies), business forums (e.g. the International Chamber of Commerce) and civil society organizations (e.g. Privacy International and the Association for Progressive Communications). A wide variety of civil society organizations are increasingly engaged in ICT forums in order to have their perspective reflected in ICT debates.

Pivotal role of governments

While the above groups are active in seeking influence at the international level, government policy at the national level can have a dramatic effect on the diffusion of ICT.¹⁵ It is governments that create the policy environment that will foster technology use and encourage national and international investment in ICT infrastructure, development and a skilled workforce. Government action is also important in extending the benefits of technology to all social groups, as governments have the power and mandate to balance the needs of their citizens for long-term economic growth and social prosperity. Ultimately, how and what users have access to depend on specific legal, economic, political and social conditions. Not least, national systems of innovation strongly influence the diffusion process in a country.¹⁶

Linking health goals to ICT policy

ICT represents not a single innovation but rather a cluster of related technologies that must be present together to support adoption by users, such as servers, communication links, software and user devices. In the simple model shown in Figure 2.2 there are three levels. At the bottom, is the connectivity level or underlying telecommunications and network infrastructure level, without which there can be no ICT. In the middle, a services level consists of organizations providing ICT applications and services, reflecting the extent to which ICT services are available in a country. At the top, is the individual and organizational user level, where ICT adoption is typically measured by the overall number of users in a country.¹⁷

Policy implemented at each level affects meaningful access to ICT in a country and therefore in the health sector. Policies on the infrastructure level provide the basis for expanding physical infrastructure such as satellite, wireless and broadband by shaping market conditions and competition. Providing access to technology is critical, but more than physical access is necessary. Networks and services are insufficient if ICT is not used because it is not affordable, people cannot understand how to use it or the local economy cannot sustain its use. Policies at the services level therefore shape the legal and regulatory framework that creates conditions for a viable, secure online environment, promotes diffusion and uptake of services, and supports minimum levels of consumer protection. At the user level, a wide range of government and organizational policies affect user adoption and conditions of use. For example, a United Nations group has developed an index of ICT diffusion.¹⁸ This considers the indicators for Internet access in a country as including Internet users per 1000 inhabitants, adult literacy rate, cost of a 3-minute fixed-line telephone call and gross domestic product (GDP) per capita. Seen from this broad perspective, government investment and policies to boost literacy – as much as direct involvement in ICT policy – are important in ensuring that all citizens can benefit from ICT.

Figure 2.2 A simple framework for understanding ICT policy. (Adapted from Wolcott et al.¹⁷)

Health policy makers in the process of developing or implementing national e-health strategies need to be able to work effectively with ICT policy makers. However, there are few precedents for cooperation between the sectors and little experience to draw on to align policy interests.

Linking health and ICT policy

The potential points of influence, or entry points, in a complex environment such as ICT policy are not necessarily obvious. At a minimum, national health policy makers need to know the basics of ICT policy objectives and approaches in order to be effective advocates for improving infrastructure, access and affordability, or for obtaining concessions or aid for the health sector. While every country is unique, national policies generally set out goals and objectives for the development of the ICT industry, development of the economy and support for key sectors of the economy. The list below highlights core elements included in national ICT policy.

Core content of ICT policy

The core content of any ICT policy must include five factors:

1. Infrastructure development. These policies promote the development, expansion, operation and increased efficiency of ICT networks at the infrastructure level. This is an area of great interest to the health sector, but not traditionally one where the sector has much influence. Those involved include governments (ministries of information technology and telecommunications), the private sector (multinational corporations), independent bodies (regulators) and international organizations (International Telecommunication Union).
   
   
2. Universal and equitable access to ICT services. These policies, implemented primarily at the infrastructure and services level, aim to improve the availability and affordability of ICT services. They are designed to facilitate access to ICT networks and services for all citizens, as well as for under-served groups such as the disabled and women. This area is of vital interest to the health sector, and is becoming more open to influence as policy-makers strive for more transparent and inclusive policy-making processes.
   
   
3. Promotion of market competition. Policies in this area aim to stimulate ICT development and adoption by creating an environment for fair competition between providers of infrastructure and services, corresponding to the infrastructure and service levels of the model. Outcomes are of great interest to the health sector, but this is not typically an area of direct influence.
   
   
4. ICT as a means of achieving national social and economic goals. These policies are designed to exploit ICT in achieving national social and economic goals, such as health, education and economic development. Policies in this area correspond to the service and user levels of the model. This is a natural and realistic entry point for the health sector in policy discussions.
   
   
5. Encouraging private sector investment. Policies aim to promote private enterprise development of ICT infrastructure and services. Policies in this area correspond to the infrastructure and services levels of the model, and are also related to overall government policies for transparency, accountability, anti-corruption and so on. Robust and sustainable private sector investment in ICT benefits the health sector, and this policy area is increasingly open to sectoral advocacy and influence. There are significant variations in telecommunications investment across the world.⁴

Countries place different emphasis on the above elements, depending on factors such as their level of economic development, the strength and maturity of the private sector, the orientation of development partners and existing policy capacity. For example, one country may see a need for stronger emphasis on competition in services rather than on expansion of ICT infrastructure. Examples of ICT policy and potential impact on the health sector are highlighted in Table 2.2.

Factors affecting ICT use in the health sector

There are several factors that affect the use of ICT in the health sector. These include costs, access speed, education and collaboration between stakeholders.

Costs for ICT

These influence uptake in all sectors. They are normally reflected at the service level, and incorporate the costs passed on to the user from the infrastructure level. In general, two basic disparities exist in the affordability of ICT: in the basic cost of the technology and in the cost relative to per capita income. Access costs such as high Internet service provider and telephone call fees can be two to four times as high in developing countries as in developed market economies.¹⁹ When the monthly cost for Internet access exceeds the monthly income of a significant proportion of the population, its level of use will remain low.

Access speed

This directly affects cost. In nearly all countries, telephone calls are charged on a per-minute basis for telephone mainlines, with an additional access charge. Where Internet access is through a dial-up connection, download times are long, and costs therefore increase. The trend to using large web pages and files is not an obstacle in countries where bandwidth is increasing, but in low-income countries the long download time further increases the cost. Although telemedicine can be successfully practised via low-bandwidth connections, lack of affordable broadband infrastructure significantly hampers the ability to conduct telemedicine applications where transfer of high-resolution images is required (see Chapter 13 and 19).

Education

This clearly affects ICT use, and international disparities are evident at the user level. The degree of technical capacity at this level is a result of long-standing government investment or under-investment in education and training, not only through initiatives such as staff development programmes and technical training in schools, but also including investment in secondary and tertiary education.

Collaboration between stakeholders

At the infrastructure and service levels, regulations such as those for importation of telecommunications equipment in emergency situations show the need for cross-border collaboration in ICT and health. Clearly, ICT is central to an effective health sector response in disaster situations, whether natural disasters or man-made (e.g. armed conflict). In the absence of formally established procedures covering disasters and emergencies, customs clearance and type-approval procedures for telecommunications equipment, allocation of radiofrequencies and authorization for radio communications can delay installation of urgently needed communications systems. For example, regulations on telecommunications equipment importation and type approval delayed help when a non-governmental organization arrived to install radio communications in Bam, Iran after a major earthquake in 2004. Lengthy national and local customs and telecommunications regulatory clearance resulted in an unnecessary and costly delay before the equipment could be installed where needed.

Legal framework, skills and protections for a
network economy

Trends in the uptake of advanced applications of ICT such as e-commerce show even greater disparities than trends in basic access to computers. Many countries still lack the infrastructure, capacity and resources to develop and manage health applications, including those emerging from e-commerce and e-government. Without these prerequisites, ICT in health will not grow significantly in developing countries. Furthermore, countries must have the skills of a networked society in order to deal with common challenges and threats. For example, security threats are growing and are becoming more malicious, damaging and widespread, with serious implications for countries. Threats to a networked economy include spam and security violations. These are increasingly propagated from developing countries with weak laws, weak policies and inadequate security. The consequences can be severe for developing countries, where awareness, protection tools, legislation and enforcement are still underdeveloped.²⁰ Basic measures are required to ensure that security threats emanating from developing countries do not pose a threat to the Internet. Collaboration is essential in this respect, to ensure that technology resources are not diverted from the health area to deal with these security concerns.

ICT policy orientation in middle- and high-income countries

At the policy level, most high-income countries maintain a separation between government ministries in charge of telecommunications and information technology.²¹ However, telecommunications policy makers and regulators are increasingly attempting to incorporate the entire range of ICT in their policy domains. While health is often mentioned in the list of general benefits of ICT to society, the specific benefits of ICT for the health sector are rarely mentioned in ICT policy statements. It is also rare to find specific actions or commitments by ICT policy makers to improve health, which is often viewed as a sector that would benefit from the latest developments in ICT. In this context, health applications often appear in policy programmes mainly to justify the importance of broadband technologies.

While the interests of the health and ICT sectors appear to be shared at conceptual levels, they are not in practice implemented to the extent that might be desired. For example, policy makers may view the health sector as a test bed for the application of high-speed telecommunications systems. The health sector would certainly benefit from the network technologies that enable transmission of the images used in medical diagnosis. It is questionable, however, whether ICT policy makers recognize these benefits and subsequently afford high priority to the health community.

Private sector ICT vendors naturally have technology-centred views and are concerned with health as a business. They are interested in digital opportunity, rather than the digital divide. They explore business opportunities to sell ICT equipment and systems. The lack of telecommunications infrastructure in rural areas may be perceived as a business opportunity for a vendor to prove the benefits of wireless broadband systems, but unless this can be profitable, it will not be sustained or implemented on a large scale.

ICT policy orientation in low- and middle-income countries

Lack of reliable infrastructure is a severe constraint for low- and middle-income countries. The lack of adequate infrastructure to support high-quality, high-speed Internet connections is a major obstacle for economic and social development, and lack of bandwidth excludes countries from taking part in the global information society. A fundamental challenge is the cost of bandwidth, which, because of policy, regulation and technology challenges, can be up to 50 times as high as the cost of bandwidth in industrialized countries.¹⁹ Operational costs on this scale put ICT out of reach for the health sector, and represent a difficult trade-off for government decision makers when considering how best to allocate health and social welfare budgets.

Provision of basic ICT services to the general public is becoming a high priority as donor-financed initiatives are beginning to stress core policy reform, incentives for private sector investment towards providing access to rural and underserved areas, development of national backbone links, and deployment of broadband and government networks.²² This long-term perspective represents a significant shift from the previous decade of project-based ICT development initiatives such as tele-centres, where the benefits to the health sector were often mentioned in the rationale for their construction but where in reality the benefits were rarely realized.

Opportunities presented by policy reform processes

Policy reform processes in countries can provide an opportunity for the health sector to participate in consultations when ICT policy is being developed or revised. Countries trying to improve policy making may also require training or guidelines for the public sector policy process that specifically mandate broad consultation with stakeholder groups. For example, it is evident that ICT policy makers would benefit from understanding how policy affects the technology users in all sectors. This can be achieved by means of evaluation, consultation mechanisms or a combination of the two. A government mandate for input, dialogue and better information flow provides a good starting point. At the least, the sectors can acknowledge each other’s interests and responsibilities, although they may not share the same perspective or priorities.

Policy adjustment to meet local needs

It would seem obvious that policy directions must reflect and be adapted to the local context, but this is not always the case in ICT policy. Often, basic ICT policy principles are agreed at the international level, or policies of high-income countries are simply transferred to low- and middle-income countries. However, the local context – in terms of local needs, skills and political issues – has a significant effect on whether generally accepted policy reforms are adopted and put into practice. Even national governments with the political will to drive change often face challenges in putting policies into effect, particularly where the necessary legal framework and human resources are lacking.

Opportunities for action

There is much that the health sector can achieve by becoming actively involved in ICT policy making, particularly in the long term. But the health sector may first need to build its own capacity to use evidence and information for policy and planning. A country’s level of ICT diffusion and general policy-making capacity will show the potential areas for focus and action. The following are some examples.

A holistic approach to ICT development

ICT is an enabler, not an end in itself, and national ICT strategy should be ‘outward looking’ and designed to ensure effective fulfilment of national development activities. ICT strategy should ensure that there is compatibility across government sectors (e.g. access and security protocols, and user interfaces). Resources should be provided for initiatives that produce significant cost savings and improve services to users.

A growing number of countries are seeking assistance to develop sector-based ICT programmes, including e-education, e-health and e-government. However, without an overall coordination mechanism at the country level, these ICT programmes may lead to sector-specific ICT infrastructure owned and operated by the relevant ministry, thereby duplicating private sector or other infrastructure. A holistic approach is required, with governments ensuring that investment in ICT is coherent and sufficient to meet common needs across the sectors. The health sector may need to lobby for a more active role in policy formulation. This is possible by highlighting existing policies that show their investment and commitment to benefiting from ICT. For example, a coordinated framework may have been developed for the integration of ICT services in district health settings. There may already be arrangements for improving managerial and technical competence to oversee e-health projects. Or projects may already be planned and funded, thereby ensuring that the health sector will obtain a substantial benefit when ICT becomes more readily available. Not least, health policy makers should be aware of the relevant policy trends in other countries and build on documented experience.

Making the case for health

ICT infrastructure, costs, human resources and telecommunications regulations are four major factors that shape the development and uptake of ICT. Health policy makers must work to ensure that policies in these four areas align with health interests wherever possible. Policy makers should therefore anticipate their needs and requirements for infrastructure and bandwidth. They should propose benchmark targets for access to basic services, cost of basic services and establishment of new services for the sector. This requires more than awareness: it requires understanding and planning for what ICT can bring on a medium- to long-term basis. Policy makers should be able to articulate the drivers for access to ICT, and the potential effects of ICT policy change. High-level need and justification are important factors in ICT allocation and policy change.

Health policy makers should have an understanding of ICT solutions that can potentially be provided at low cost to meet the sector’s needs. They must also be aware of new solutions (e.g. low-cost voice communication over the Internet) that may be prohibited by telecommunications regulations in some countries. Such knowledge will provide health policy makers with alternatives in the choice of appropriate ICT policy mechanisms.

The costs of ICT services can be expected to be an important factor for some time to come. To improve rates and services, health policy makers must be able to indicate at what level they would consider operating costs to be reasonable and sustainable. This should be based on the funding model and resources of the health sector. Across a country or set of countries, it should be possible to calculate what percentage of gross income of the subsectors could be reasonably spent on ICT services and systems and what potential funding mechanisms might be considered.

Participation in a networked economy requires expertise and resources for dealing with global technical security threats, including viruses and email spam. The sector must be able to show adequate capacity to respond to threats in a networked environment, not only to protect the sector but also so as not to pose a threat to others. Where ICT is relatively new, planning is required to develop the necessary human resources capacity, and in this the health sector must be proactive. Gaps in skills should be identified and a plan developed for training and long-term staff development and retention.

Outlook for the future

Developing countries must boost their capacity in ICT and policy making. Basic ICT access indicators cannot demonstrate the full extent of ICT divides. Countries that are crippled by poverty, disease, foreign debt and corruption may not have the resources or the political will to invest in ICT or be considered good markets for foreign ICT investment. Countries must boost their policy-making capacity in order to ensure that their ICT policy addresses the concerns of multiple stakeholders. Even as the use of basic ICT increases, the control of advanced technology will require an environment based on a comprehensive ICT policy that reflects domestic as well as international interests.

For the future, international and domestic divisions in ICT use will be shaped by a number of factors that have the potential to widen or close the gap. These include the following:

• new technology solutions, such as automatic translation services and inexpensive wireless phone-based Internet;
  
  
• increasing global coverage of satellite systems and lower costs for access;
  
  
• concerted action to diffuse ICT and help people use it effectively;
  
  
• broad economic and trade policies that will spur integration of ICT into the global economy as a key engine for growth;
  
  
• improved governance and standards setting and the need for evolving models to improve inclusion and representation of stakeholders.

Boosting government awareness and capacity is central to achieving equitable, affordable ICT for the health sector in all countries. The health sector has an important role. Those involved can take concrete action as follows:

• actively participate in the ICT policy debate to improve awareness and understanding of the needs of the sector;
  
  
• emphasize that benefits to the health community also benefit the public at large;
  
  
• educate ICT vendors to develop equipment and systems that meet the needs of developing countries, i.e. low cost, durable and easy maintenance;
  
  
• work with non-governmental organizations and civil society, who have an interest in improving ICT access for the public;
  
  
• learn from each other, in order to improve input and participation in ICT policy debate on such issues as costs, infrastructure development, access to the Internet, content in local languages and privacy protection.

Conclusion

ICT is fundamental to providing effective and efficient health services and systems. These technologies can improve workforce and workplace efficiency and boost quality of care by reducing medical errors, reducing costs and improving safety. They provide networks and tools for learning, research and practice. They enable access to information, products and advice for disease prevention and management, and will be essential to the move to personalized health and care in the future.

There are many opportunities for health policy makers to influence the ICT policy process. Their chances of success will be improved by understanding how ICT can benefit health. Health policy makers must be effective advocates for health concerns and must be able to enumerate the effects of ICT policies on health. For policy makers committed to improving national health systems, participating in the national ICT policy-making process is essential to ensure that national ICT policy, when implemented, will meet the interests of the health sector.

Acknowledgements

I thank Ms Yoshiko Kurisaki, SITA, Geneva, Switzerland for preliminary discussions and Mr Shubhabrata Roy, Microsoft, UK, for his assistance with data and graphics.

Further reading

World Health Organization. World Health Assembly Resolution WHA58.1: Health action in relation to crises and disasters, with particular emphasis on the earthquakes and tsunamis of 26 December 2004. Available at: www.who.int/gb/ebwha/pdf_files/WHA58-REC1/english/Resolutions.pdf.

World Health Organization. Connecting for Health: Global Vision, Local Insight. Report for the World Summit on the Information Society. Country Profiles 2006. Available at: www.who.int/kms/resources/wsis_country_profiles.pdf.

European Commission. E-health: Better Healthcare for Europe. Available at: ec.europa.eu/information_society/activities/health/index_en.htm.

References

¹ United Nations Statistical Division. Millennium Development Goals and Targets. Available at: unstats.un.org/unsd/mi/pdf/mdglist.pdf.

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