Developing eHealth policies for greater equity in Kenya
Using information and communication technologies to extend healthcare to poor and marginalized populations in Kenya seems an obvious choice. Kenya’s remote rural regions suffer from a dire shortage of health workers and health facilities, yet more than 90% of the country is covered by mobile services.
Although this strong mobile penetration has led to a boom in eHealth projects, research carried out by the KEMRI-Wellcome Trust Research Programme reveals that it has not made healthcare more accessible across the country.
A map developed to identify the country’s eHealth projects, the first such undertaking in Kenya, shows that the 70 ongoing initiatives are clustered in and around the cities of Nairobi, Kisumu, and Mombasa. In the arid and semi-arid regions of the country, home to the people most in need of services, eHealth projects are few and far between.
According to the researchers, the lack of a well-defined national eHealth strategy and standards contributes to this inequitable distribution of services, as well as to duplication and wastage of resources.
Mapping eHealth coverage
With IDRC funding, in 2013 the researchers set out to determine if and how eHealth interventions foster health equity and improve health system governance. Were health services available in a timely and affordable manner to those who needed them? Were decisions about health made in a transparent manner and with the participation of all stakeholders?
The research found that, despite good intentions and the launch of a series of government initiatives to address health system challenges, plenty of work remains to make quality healthcare available to all.
One of those initiatives was the 2011 launch of the country’s first National eHealth Strategy to achieve equity in healthcare. Recognizing the potential of information technologies to improve health systems, it targeted five key areas: telemedicine; electronic health records; information for citizens; mHealth (the use of mobile technologies in health); and eLearning or distance education to boost health professionals’ knowledge.
Researchers found that most existing eHealth projects addressed these priorities, with a strong bias toward mHealth. In fact, the findings revealed that 69% of the initiatives rely on mobile phones.
The mapping showed focus areas emerging across the 70 programs, such as extending geographic access to health services, enhancing data management, providing education to health workers, and improving diagnosis. Promoting healthy behaviour was a common theme, particularly concerning primary care, HIV/AIDS, and maternal, newborn, and child health.
Good intentions, poor implementation
However, the researchers also found that the bulk of the interventions had been developed by donor-funded non-governmental organizations. Because each was implemented in isolation and without Ministry of Health (MoH) approval, few were aligned with national needs or priorities. Lack of government buy-in and funding led to the abandonment of many projects after a pilot phase.
Researchers also found that eHealth users and care providers had not been consulted during the projects’ design, therefore programs did not reflect their needs. Increasing communities’ participation in decision-making could improve the initiatives’ accountability and governance, and create a greater sense of ownership.
Researchers found that only eight projects had been systematically evaluated and only one had undergone a cost-effectiveness analysis. As a result, little was known about their impact and few lessons had been drawn about success factors or failures.
Researchers were also concerned about how many interventions focused on similar issues, leading to duplication and fragmentation. Another challenge was the lack of integration with the national health information system, which prevented the ability to share valuable information between them or with the MoH. They found that many eHealth implementers were reluctant to share information, including details about the hardware and software used, thus limiting the MoH’s ability to leverage achievements and build on lessons.
Toward an eHealth policy and framework
Kenya lacked a regulatory eHealth framework at the start of the project, including standards, guidelines, and supporting policies. This limited the government’s stewardship and commitment, which is important for ensuring the sustainability of projects. The research team worked closely with the MoH eHealth unit from project formulation through to its implementation, and engaged with stakeholders from implementing organizations, users, and frontline health workers.
The mapping of all eHealth interventions has been shared with MoH and other stakeholders to encourage collaboration, consultations, harmonization, and integration in the overall healthcare system. The ministry is now developing a framework to certify all eHealth innovations at all levels of the health system. This will reduce duplication and encourage the use of common platforms.
Findings from this mapping point to the need for ongoing dialogue among key stakeholders — from the MoH, NGOs, and donor agencies — to improve the relevance and sustainability of the various eHealth efforts.
The research also flagged issues of data security and confidentiality when the team discovered that data collected from eHealth interventions was often stored on servers outside of Kenya. In response, the MoH and the University of Nairobi are developing a common server to store data in-country.
The findings are now being used to inform the review of the earlier eHealth strategy, to formulate the country’s first eHealth policy, and to develop standards and guidelines. Guides to standardize hardware and software systems to ensure interoperability and set common standards for mHealth systems are also being prepared.
As the researchers point out, results from this study will benefit Kenya’s eHealth programs and have long-term health benefits for all Kenyans. They will also feed into international debates on how to best implement eHealth to promote health equity and governance.