In an age where the already overburdened West African health system is put under even more strain from communicable disease outbreaks, the need for effective, interoperable eHealth systems to monitor and track disease patterns and patients has never been more crucial. eHealth Africa’s (eHA) Program Manager, Polio and Lead, Business Development, Anu Parvatiyar, and Head of Software Department, Justin Lorenzon, share their experience and expertise on what makes an African eHealth programme effective and sustainable.

African Footprint

Founded in 2009 to work on maternal health and polio in Kano, Northern Nigeria, eHA has since expanded its work to other West African nations, such as Guinea, Sierra Leone and Liberia, in response to the Ebola outbreak in 2014 with the aim of developing and implementing eHealth projects to strengthen public health systems.

eHA is strategically headquartered in Kano to ensure that the eHealth solutions they develop stay relevant to the local African context. In Kano, the health system is substantially weaker compared to the south of Nigeria due to socio-economic factors. “The level of infrastructure and sophistication in a lot of the clinics is very low, making interventions all the more necessary,” said Parvatiyar.

“Developing eHealth technology from the ground is a game changer in this space,” said Lorenzon. “There’s a trend whereby smart and well-intentioned people in places like Silicon Valley create eHealth solutions for developing countries which, in reality, fail to meet the needs of its intended user group. By working on the ground with health workers in facilities that are often completely off the grid and rely on solar fridges for power, for example, our logistics team can envision and design eHealth innovations that are relevant for the setting.”

When Ebola hit Lagos in 2014, eHA uncovered a critical gap in the healthcare space. “eHA was fairly new to the disease response space, so we assumed there would be a well-developed ecosystem of tools for managing the outbreak data. However, nothing was up to the task of managing activities and sharing and acting on the data in real-time,” said Lorenzon.

In response, eHA used readily available open sourced tools to develop eHealth response systems to connect multiple work streams and help the response teams deal with the overwhelming logistics and patient management required to carry out rapid diagnostics.

Policy and Design Don’t Marry

While the systems eHA developed were successful in helping curb the spread of the Ebola epidemic, continuous political challenges exist which hinder the healthy development of eHealth systems.

“We work in multi-stakeholder environments where there’s a lack of clear and easily applicable data sharing protocols and governance,” said Lorenzon. “In each case, specific MOUs need to be developed with partners and government; however it’s reflex to be conservative with data sharing, which hampers interoperability. So there is a fundamental lack of marriage between policy and technical decision making.”

This leads to a situation where there isn’t capacity in decision making to evaluate technical proposals as they arise. “Different organisations propose different eHealth solutions which would benefit the system, but the inability to evaluate and make decisions on what should be implemented, often nothing is implemented as a result,” said Lorenzon. “I’ve seen situations in some of our target countries where local entrepreneurs want to get into the space and have a lot to offer, but they can’t break in because there are large institutional partners that have a particular eHealth platform that is understood as a solution that will cover everyone’s needs. This means other solutions that may be better lose out.”

In addition, it’s common practice for external consultants to be hired for technical input when it comes to IT, resulting in IT not being integrated within central decision making circles. ”There’s not enough leadership and understanding of eHealth at the government level,” said Lorenzon. “In the private sector technology is central to the enterprise and strategic planning, so while I think the same will happen in the public sector unfortunately, I don’t see it happening any time soon.”

According to Parvatiyar it all comes down to the current mind-set. “In Nigeria, data is collected for the sake of reporting, and not necessarily for decision making. It’s a challenge to spur the mental shift in the public sector to look at the data they have and take the appropriate action. Decisions in the public sector need to be made by the government, and it’s not easy to see how they are using data to make decisions.”

Interoperability is More than a Buzz Word

While interoperability has become a buzzword of late, according to Lorenzon, when implementing an eHealth system it’s important to know: what interoperability is needed for; what are the processes on the people and practice side; what the change management process is; and, what are you trying to achieve. “eHealth technology is useless unless you have a process supporting it and interoperability is no exception,” said Lorenzon.

“It might seem contradictory, but interoperability is often seen as a way to leverage a small number of large scale systems that are very popular in the public health space. Interoperability is seen as technical problem that needs to be solved, but that’s the wrong way to go about doing it because interoperability has been solved,” continued Lorenzon.

According to Lorenzon, the tech community has already developed robust ways of arbitrating data exchange. “Interoperability is not a tech problem that needs bespoke solutions. Rather, part of the problem is that the space doesn’t tolerate duplication,” said Lorenzon. “I however think duplication isn’t the problem, but rather the lack thereof. There may be many tools in play, none of which actually address the real problems, and solutions are blocked because it’s perceived that something is already there and we don’t want to duplicate efforts; it’s a false conflict that blocks a lot of development.”

Once again, the challenge is that there aren’t governance frameworks to support a multiplicity of eHealth systems. “It’ll be interesting to see what happens in the next couple of years, I predict systems will become less monolithic and there will be more small scale interoperable systems, however it all has to be driven by need,” said Lorenzon.

Achieving Success

Despite the abundance of challenges the organisation faces on a daily basis, eHA has seen their work pay off, especially with their vaccination tracking and polio campaigns. “It’s been encouraging to see the impact the programme has had and what we can achieve. Nigeria has now gone 11 months without a case of paralysis from wild poliovirus,” said Parvatiyar. “Small changes can have a huge impact on how health systems function. A small deployment can really change the game of how data is collected, used, analysed and transmitted.”

By using an innovative and extensive geographic information system (GIS)-based tracking programme, eHA was able to map vaccinations against GIS data for communities that were often missed out in the campaigns due to lack of infrastructure or a social divide.

“Routine immunisation has made a significant contribution to discussions around coverage and has led to the digitisation of mapping and the supply chain for certain vaccines, which has reduced stock outs significantly,” said Lorenzon.

The generated data has also been useful in mapping network coverage, leading to upgrades and improvements in certain areas. “A new mobile platform that we’ve built in partnership with government and donors, Kano Connect, has become a data collection mechanism to connect health facilities to user groups in the vicinity,” said Parvatiyar. “While it is still in an infancy stage, it’s already being used to map vaccine levels across facilities so healthcare workers can know where stock barriers are, how supply chains are moving, cold-chain capacity and where fridges are broken – things that have never been done before.”

Ongoing Effort

Primarily based in Kano, eHA recently set up a tech team operating out of Berlin to engage with its innovative tech start-up community. “While plenty of people in Nigeria have good tech ability, they don’t have the same development culture in software engineering as Berlin. There are a million ways to do something, but not all will be sustainable or work well in a team setting or work at scale,” said Lorenzon.

Through regular rotations, eHA has been importing the professional culture and community of practice from the Berlin technology scene to their Kano office to build skills capacity and eHealth systems. “The two teams work closely and sync up on weekly basis to demo stuff to each other and talk about technical issues,” said Lorenzon.

Both teams are sent out to the field to carry out deployment testing, as nothing replaces field experience. “By bringing the highly developed engineering culture of Berlin to local teams, the local teams in return are able to give context awareness to the tech teams,” said Lorenzon.

eHA’s eHealth systems are designed for use by a wide target audience, including doctors, nurses and, most prominently, officers in charge of health facilities and logistics officers who often have only basic healthcare training. “There’s a tremendous amount of receptivity to change if a system is perceived as making a person’s life easier and it’s relevant to their work,” said Lorenzon. “If we put out a tool that’s not seen as useful it’ll be dropped instantaneously.”

eHA’s primary design principle is that any solution they deploy should be re-trainable by somebody else to avoid having to gather a large group of people from various locations for training sessions.” We realised it’s impossible to organise an in-person training programme for every single person that is going to touch that device ,” said Parvatiyar.

“The user interfaces are very intuitive, so of course while some are initially intimidated by the tools the majority are willing to play with it to explore and figure out what’s going on,” added Lorenzon.

Extending the Reach

Over the past year eHA has expanded its initiative from Nigeria to other West African countries after being invited by the respective governments to help strengthen their public health systems. In the future the organisation plans to take a more proactive role in building relationships with other local partners and government representatives to offer help based on their core competencies. “It’s really important to develop government partnerships in order for the programmes to succeed,” said Lorenzon.

While eHA hasn’t worked in South Africa as of yet, they have been in contact with BroadReach and Mezzanine and look forward to doing work in SA depending on government buy in.

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