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Lessons Learned From Implementing E-Learning for the Education of Health Professionals in Resource-Constrained Countries

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The growing global demand for tertiary education has led to the increased use of e-learning approaches around the world. Demand has increased most rapidly in low and middle income countries (LMICs), which account for half of the students currently enrolled in higher educational institutions (HEIs). But the implementation of e-learning programmes in resource-constrained settings faces many obstacles. This paper explores some of the key issues involved in implementation of e-learning in HEIs involved in the education of health professionals, given the resource constraints within which many institutions have to function. We present case studies of three such LMIC institutions of varying size and primary purpose. The paper suggests use of appropriate ICT infrastructure, both in terms of hardware and software, combined with effective access and bandwidth management policies is crucial to the successful implementation of e-learning courses on health within HEIs based in LMICs.
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Reference this paper as: Gupta M et al, “Lessons Learned From Implementing E-Learning for the Education of Health
Professionals in Resource-Constrained Countries” The Electronic Journal of e-Learning Volume 15 Issue 2 2017, (pp144-155)
available online at www.ejel.org
Lessons Learned From Implementing E-Learning for the Education
of Health Professionals in Resource-Constrained Countries
Manu Gupta1, Sophie Marsden2, Tony Oluka3, Reetu Sharma4 and Henry Lucas5
1Corresponding Author: Institute of Health Management Research, 1-Prabhu Dayal Marg, Near
Sanganer Airport, 302029, Jaipur Rajasthan (India)
2Institute of Development Studies, Brighton (UK)
3Makerere University, Kampala, Uganda
4Indian Institute for Public Health Gandhinagar, Ahmedabad – 380 054, India
5Institute of Development Studies, Brighton (UK)
manugupta08@gmail.com
S.Marsden@ids.ac.uk
toluka@dicts.mak.ac.ug
rsharma@iiphg.org
H.Lucas@ids.ac.uk
Abstract: The growing global demand for tertiary education has led to the increased use of e-learning approaches around
the world. Demand has increased most rapidly in low and middle income countries (LMICs), which account for half of the
students currently enrolled in higher educational institutions (HEIs). But the implementation of e-learning programmes in
resource-constrained settings faces many obstacles. This paper explores some of the key issues involved in implementation
of e-learning in HEIs involved in the education of health professionals, given the resource constraints within which many
institutions have to function. We present case studies of three such LMIC institutions of varying size and primary purpose.
The paper suggests use of appropriate ICT infrastructure, both in terms of hardware and software, combined with effective
access and bandwidth management policies is crucial to the successful implementation of e-learning courses on health
within HEIs based in LMICs.
Keywords: e-learning; global health education; connectivity; bandwidth management; capacity building; educational
technologies
1. Introduction
The development of innovative ICTs, increased accessibility of the internet, and a growing global demand for
tertiary education (Wende, 2003) has stimulated interest in e-learning – the use of digital or electronic
technologies and materials to support teaching and learning” (Power, 2014) – in many countries (Tinio, 2002).
Investment in e-learning has the potential to provide high quality teaching at a lower long-term cost per
student (Bates, 1995 ; Olsen, 2015), though initial costs may be higher (Kumpu, et al., 2016). It has been
argued that the internet provides opportunities for the development of a ‘global classroom’ where individuals
can learn in distant locations, at different times, and at their own pace, leading to a “borderless education …
that crosses the boundaries of both time and space” (Middlehurst, 2006). By extending access to health
professionals who are highly motivated but struggle to overcome the financial and social costs associated with
full time attendance at a tertiary education institution, e-learning could contribute to capacity building in
resource poor regions where they are most needed (Marrinan, et al., 2015; Hvorecký, et al., 2005).
The global demand for higher education is rising rapidly, with over 150 million people estimated to be seeking
tertiary education by the year 2025 (Suhail, Lubega and Maiga, 2014). This demand is particularly prevalent in
those ‘low and middle-income countries’ (LMICs), as defined by the World Bank, which account for half of the
students currently enrolled in higher education institutions (World Bank, 2000). In particular, there is a rapidly
increasing demand for global health related courses (Kerry, et al., 2011), which is reflected in the 34% growth
in the number of recognised medical schools over the five years from 2007, many in LMICs (Duvivier, et al.,
2014). In resource-poor environments, the advantages of e-learning may offer a way to satisfy this demand.
There has been strong support in many LMICs for the integration of e-learning into existing healthcare
teaching programmes, given a recognition of the need to substantially increase the number of qualified
providers and ensure their more equitable distribution within a context of limited financial resources and
academic staff (Frehywot, et al., 2013 ; Bollinger, Mckenzie-White and Gupta, 2011). However, implementers
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of e-learning programmes in these settings face many obstacles. Experience has taught that the integration of
ICTs into the activities of any organization is a complex process that needs careful conceptualization and
detailed planning (Greenhalgh and Stones, 2010). There are also obvious cost implications associated with
both the initial acquisition of required hardware and software and, often not sufficiently considered, its long
term maintenance and eventual replacement (Kumpu, 2016; Khan, Hasan and Clement, 2012). Even where
financial constraints can be overcome, a lack of suitably qualified and experienced personnel may be a serious
limitation, given that the success of e-learning projects is “often dependent on the skills and quality of
technical support provided to end-users” (Gray, Ryan and Coulon, 2003). Without such support, the ability of
even the most enthusiastic teachers and students to access and use the technology effectively may be severely
hindered (Prostiv and Atkins, 2016 ; Valdez, et al. ,2004) . Users need continuous and timely help from
technical departments, which may prove very difficult to provide when resources are severely limited
(Moolman and Blignaut, 2008). Here we address some of the technical and logistical constraints to be
negotiated by those attempting to develop new e-learning initiatives.
2. Methods
The aim of the paper is to inform those wishing to explore the potential for e-learning in courses targeting the
health professions in HEIs using case studies from three institutions that deliver such courses. The case study
approach seemed most appropriate, given that there has been limited previous research in this area. It
seemed reasonable to assume that multiple interacting factors, concerning which we have at best anecdotal
knowledge, would play a role in determining the relative success or failure of e-learning initiatives, and that
those factors might vary considerably between institutions. The possibility that a case study could “examine a
particular instance but illuminate a general problem” (Merriam, pp. 30) seemed most appropriate to the
present task.
We selected the case studies from the twelve academic institutions in LMICs that collaborated on a recent e-
learning project (Lucas and Kinsman, 2016). Selection was based on the diversity of the cases, in terms of both
size and purpose. On this basis we selected: a major university with a prestigious College of Health Sciences; a
medium size health research institute; and a relatively small academic institute primarily concerned with the
education of health professionals. The case studies were conducted by three of the authors in their own
institutions. They were conducted using a combination of their existing knowledge, a review of the variety of
internal documents detailing the evolution of e-learning activities, and a series of semi-structured interview
with key informants, both those involved in the development of courses and those supporting the use of ICTs
in their implementation. The interviews focused on the resource and technical issues that arose during the
design and implementation of relevant courses. In particular, they addressed: current, planned and potential
e-learning activities; the main challenges encountered in course implementation; and strategies adopted or
suggested to overcome those challenges.
Whilst we recognise that there is great variation between resource constrained countries and between
individual institutions in those countries, we aim to identify some key issues raised in one or more of the
studies and consider the approaches used to address them, in the hope that this may assist other health sector
organisations who wish to incorporate e-learning into their training programmes.
3. Findings
3.1 Case Study One: Indian Institute for Health Management and Research (IIHMR), India
The IIHMR (Jaipur) is a university in Rajasthan, northwest India. It focuses on management, research,
education and training in the health sector, with 300 students per year accepted onto its MBA courses, and
with 46 faculty members covering a wide range of disciplines. It also collaborates with Johns Hopkins
University (JHU) in offering their MPH programme as a blended learning course. This is designed to provide
high quality public health capacity building at a relatively low cost, targeting students from LMICs.
Alongside traditional modes of instruction, IIHMR uses a wide range of educational technologies, with teaching
content delivered via the internet, the Institute intranet and DVDs/CDs. Internet-based courses use an
interactive learning management system (LMS) and incorporate a range of multimedia components including
live streaming and recorded videos. The MPH course uses a LMS developed and maintained by Johns Hopkins
University, with onsite technical support provided by IIHMR. This degree of outsourcing was seen as the best
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option, given the significant financial investment, resources and expertise that an on-site server room
demands.
There is a single ICT department (12 employees) providing technical support to the Institute, including network
administration, software installation, network maintenance, resolving hardware and software problems, and
security. The Institute runs a basic digital literacy course for students, removing the need for the ICT
department to deliver such training. The internet connection is provided through both a local area network
(LAN) and a wireless network. Staff and students access the internet using 200 computers maintained by the
ICT department and connected to the LAN, or laptops and mobiles linked to the Wi-Fi network. The university
relies on leased lines from two commercial Indian ISP providers, at speeds of 20 Mbps for regular operations
and 5Mpbs as a standby option.
3.1.1 Challenges
Increased use of ICTs for educational purposes has provided many opportunities for IIHMR students but has
raised a number of managerial, financial and technical challenges. These include: providing the required
Institute-wide infrastructure (in terms of both hardware and software); designing and implementing an e-
learning platform, which involved substantial initial expenditure and a dedicated team to maintain and
upgrade it; providing support to both faculty and students; and managing bandwidth to avoid network
congestion and allocate resources in line with Institute priorities. The ICT department has identified three main
risks related to the network: excessive consumption of bandwidth; lack of compliance with Government
regulations (for example, visits to websites banned by the Indian Panel Court); wilful misuse of the system, for
example cyber bullying, computer hacking; and use of unauthorised software.
Growing use of multiple devices (mobiles, laptops, tablets) by students has led to increased consumption of
bandwidth, placing a considerable additional burden on the network. The university environment is very
challenging to monitor and manage, given the diverse range of demands on the system and potential for rapid
and sometimes unexpected fluctuations in demand over time. Many students use the internet not only for
educational purposes but to access social media sites or download music and videos. Such activities may
consume much of the bandwidth and substantially downgrade access for other users. However, they are very
difficult to prevent without imposing constraints on those who wish, for example, to access educational
videos, download academic articles or attend relevant webinars.
3.1.2 Management strategy
In order to improve the performance of the network within existing resources, the department has adopted a
multifaceted approach to reducing congestion. This focuses on: a fair usage policy agreed with users; network
monitoring; and effective enforcement of access regulations. Network administrators monitor traffic flows,
detect and eliminate viruses and provide real-time performance indicators. The freely available monitoring
tools Wireless Network Watcher and Find Mac Address have proven very useful in identifying computers and
devices connected to the network, including laptops, tablets and mobiles, allowing resolution of IP conflicts
and restricting access where necessary.
In order to reduce overload, the ICT department uses a number of network optimization techniques:
1. A user authentication system, restricting access to the network.
2. Local caching for frequently used materials including e-textbooks and video clips.
3. Implementing a unified threat management approach (Christopoulos, 2011) using an all-in-one
security application. This also allows users to check their internet usage and generate reports (figure
1), making users aware of the demands they are making on the system.
4. Blocking peer-to-peer torrent sites used to (sometimes illegally) download video and music files,
except in exceptional circumstances and under the supervision of a member of the IT department.
5. The formation of user groups for prioritizing of network traffic.
6. Offline access to electronic mail services.
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Figure 1: Snap shot of Unified Threat Management presenting data usage by a user
3.2 Case Study two: Indian Institute of Public Health Gandhinagar (IIPHG)
The Public Health Foundation of India (PHFI) is a public-private initiative with headquarters in Haryana. It
oversees four academic institutions, the Indian Institutes of Public Health (IIPH), engaged in public health
education, training, research, and policy advocacy. IIPHG has 12 faculty and runs two full time on-campus
courses, Public Health Management and Industrial Health, and four online courses: Research Methodology;
Managerial Effectiveness for Healthcare; Health, Safety and Environment Management; and Public Health and
Hospital Management for Nursing and Allied Health Professionals. To date, 277 students have enrolled in the
online courses. A variety of technologies are used for course delivery including stand-alone computers, the
internet and DVDs. Teaching activities include webinars, video conferences, and the use of videos made by
students to facilitate classroom discussions.
Resources include around 35 desktop computers, 50 laptops, printers, still and video cameras, voice-recorders,
microphones, a LAN and Wi-Fi enabled internet facility, a computer laboratory, video conferencing facilities
and a library of educational CD/DVDs. The online courses are hosted via a Moodle based platform run on a
local server. Apart from basic course content, reference materials and assignments, each course has provision
for periodic online interactive sessions between students and faculty, a discussion board and online quizzes.
Adobe Presenter and Camtasia are used to record lectures and WiziQ for interactive sessions. The learning
platform also allows online registration, fee payment, application tracking, automatic email reminders,
certification, and student feedback. It can be accessed by enrolled students over any available internet
connection. Almost all online courses are in blended format, allowing both faculty-enabled and self-learning
modes. Each includes a series of voice-over-power-point (VOPP) lectures by faculty members.
IIPHG leases a 2 Mbs internet line for around $US3,200 per year. As indicated above, the internet is available
through LAN and Wi-Fi connections within the institute. Additionally, portable internet data cards are provided
to all faculty and research staff to facilitate internet access elsewhere. When IIPHG moves to a new campus
with upgraded ICT infrastructure, access will also be provided via mobile phones.
While PHFI has a dedicated ICT department to support the IIPHs, IIPHG has a single officer who manages all ICT
related needs. This officer has a diploma in Computer Applications, 20 years of experience and is trained in
networking and visual learning, internet security processes, network storage and digital documentation
management.
3.2.1 Challenges
Alongside increasing demand, the IIPHG distance learning platform is also evolving to meet rising student
expectations. It is planned to phase out VOPP as the primary mode of delivery in favour of approaches which
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make full use of multimedia content. Compatibility with other online applications that can add to the learning
experience such as Skype, Google Hangout and WhatsApp are also being pursued. A related challenge will be
the recruitment and retention of individuals with the qualifications and expertise in both software and
multimedia required to translate materials provided by IIPHG staff into exciting and attractive formats for
online courses.
One specific problem in the preparation of VOPP lectures is the difficulty in ensuring high quality sound. At
present recordings have to be done outside of normal working hours and noise reduction software used to
improve audio quality. As the number of distance learning courses increases, there are plans to create a
recording studio to enable higher quality audio and video materials. Plagiarism in submitted assignments by
students is another concern of faculty responsible for online courses. Manual recognition is the only safeguard
at present but with increasing student numbers there is a felt need to install and use plagiarism software.
3.2.2 Management strategy
A number of factors have led to increased demands for bandwidth, including use of multiple devices – laptops,
mobiles and tablets – by students, interactive methods of teaching online courses and live demonstrations by
faculty. Various strategies are used to address bandwidth limitations. It has been necessary to place strict
limitations on internet access by visitors and outsiders. As indicated above, the majority of lectures in online
courses are VOPP presentations. These are pre-recorded and uploaded, usually on a weekend, holiday or
evening as maximum bandwidth demand occurs during normal office hours (Fig.2 and 3). Similarly, interactive
sessions and those using live telecasts are timetabled on weekends and it has become standard practice to
record all live discussion and chat sessions held between faculty and students. Such recordings are used to
prepare question and answer banks to help students who could not attend live sessions.
Options for purchasing a higher bandwidth connection are currently being considered. A range of other ways
to improve bandwidth management are also under discussion including a dedicated firewall, single sign-on per
user option and a revised allocation policy governing bandwidth distribution to different user groups. In the
meantime, for online courses that have high student uptake and need improved bandwidth support, it may be
necessary to run parallel course units with limits on the number of students in each unit.
PHFI has a defined Internet Usage Policy and a firewall that can be used to manage and monitor network
usage. There is an automated system that monitors how many times the distance learning portal has been
accessed. This data can be analysed by course, student, location of access, etc. Within IIPHG, while a dedicated
firewall has been established for one project, none is yet operational across the institution. Currently there is
no restriction on bandwidth usage by type of user groups and no automated system to block unauthorised
websites. Additional features of some purchased software, for example the Quick Heal anti-virus package, are
installed and used in all institutional computers to block certain sites, manage cookies, intercept spam
messages, etc. Additionally, a manual bandwidth tracking system helps the IT department understand usage
patterns and restrict questionable activity, for example downloading very large files. If the latter is regarded as
necessary, specific requests must be made to the IT department to facilitate its acquisition without disruption
to other users. For example, material can be downloaded during periods of low bandwidth demand and
circulated using the local server or pen drives.
Figure 2: Broadband usage tracking system: Usage on 3rd December 2014 (Wednesday)
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Figure 3: Broadband usage tracking system: Usage on 6th December 2014 (Saturday)
3.3 Case study three: Makerere University College of Health Sciences, Uganda
Makerere is one of the oldest and most prestigious Universities in Africa. The College of Health Sciences is one
of nine constituent colleges that offer day, evening and external courses to some 42,000 undergraduates and
3,000 postgraduates. There are some 4,000 academic and administrative staff. While the College has a
considerable degree of autonomy, many ICT services are centralised and overall policy and resource allocation
decisions have to involve multiple stakeholders. The University e-learning policy aims are:
1. To improve the quality of graduates, utilizing modern instructional materials and methods,
including increased use of ICT.
2. To provide greater access to university education through non-conventional approaches in teaching
and learning i.e. distance education and a ‘virtual university’.
These goals are to be achieved by: creating an organizational and technical environment that promotes long-
term in-house e-learning training capabilities; ensuring that all students and academic staff are trained on a
continuous basis; developing university wide and global e-learning networks based on academic interest
groups and research collaborations; and establishing a common Distance Learning Environment.
The Directorate for ICT Support (DICTS) is a central service unit that provides expert services and guidance to
all academic and administrative units. It is composed of around 30 personnel with expertise including
Database Management, Systems Management, Planning and Maintenance, Networks Management and End
User Support. The e-learning function was moved to the College of Education and External Studies and
currently comprises two staff concerned with pedagogy and one with providing technical support. The
Makerere University e-learning Environment (MUELE) uses the Moodle LMS and has over 60,000 users and
1,500 courses. However, there is a tendency to use the platform as a passive repository for course materials
and not take advantage of the capacity for course management, quizzes, setting and marking assignments,
student forums, blogs, etc. Use of such facilities can be hampered by University polices which promote a
tradition model of education. There are other projects/development partners within the university that run
online courses, including the ARCADE-HSSR Project, building capacity in health systems and services research
(Guwatudde, et al., 2013), the Regional Universities Forum for Capacity Building in Agriculture, MESAU a
partnership of five academic institutions in Uganda targeting the medical education sector and VUCCnet,
focused on human resources in cancer control in Africa.
The university leases a 170Mbs connection at a cost of around US$40,000 per month from the Research and
Educational Network for Uganda, a consortium of research organizations and institutions. Optical fibre cables
were laid underground from the provider source to the university data centre to improve the quality of the link
to the NOC. Students and staff can access Internet and Intranet services using cables or via wireless routers .All
university ICT services are hosted in the DICTS Network Operating Centre (NOC) with a backup centre
approximately 2km away. Since 2005 the University has used various LMSs including Blackboard,
Kewl.NextGen and TUSK. In 2008 a decision was made to migrate all courses to Moodle. MUELE is installed on
a Power Edge 720 with 8GB RAM and 5TB of hard disk storage with backup on a Power Edge T610 with 4GB
RAM and 2.5TB of storage. It uses the Slackware Operating System and MySQL for database management.
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A number of blended courses have been run using MUELE, using both asynchronous and synchronous access
modes. The technologies used have included Adobe Connect, GoTo Meeting, Skype, SCOPIA and a dedicated
Video Conferencing facility. The university also provides OpenCourseWare, developed by the Massachusetts
Institute of Technology, and related library services including Dspace, an institutional repository application,
and Virtua, a cataloguing system.
3.3.1 Challenges
The university has experienced many challenges in implementing e-learning facilities:
1. The growth of the university and associated demand for internet access by an increasing
number of staff and students has posed serious problems in terms of available bandwidth. In
addition, because priority is given to those working on the campus, access from outside can be
severely limited, especially in terms of video and synchronous communications.
2. University policies do not encourage the use of the e-learning platform to support traditional
teaching methods – one requires students to attend all lectures face-to face.
3. A relatively small proportion of students can easily access computers to use the internet when off
campus.
4. The local network which links the University to the internet has been developed in an ad hoc
manner and services are often disrupted by the need to repair cables.
5. Blended courses using video streaming have struggled to overcome incompatibilities between
different learning hubs, which often purchase hardware and software without considering the
potential limitations in terms of ease of communication with other users if they do not adhere to
the guidelines developed by DICTS.
6. Maintaining the technical and user documentation required for the effective use of the e-learning
platform has typically proved much more time consuming than expected, resulting in those
responsible often delaying making necessary updates.
3.3.2 Management Strategy
Various actions have been taken to limit demand. Individual downloads are limited to a maximum of 100Mb
per connection during peak hours and access to YouTube, a major contributor to bandwidth consumption, is
not allowed during normal office hours. Frequently accessed web-based material is copied and stored on the
local server and all university websites and mail services are hosted within the NOC. Such actions have
substantially improved the internet experience, reducing access and download times. The University recently
procured bandwidth management software which should allow DICTS personnel to efficiently allocate
additional bandwidth to individuals or research groups with specific needs, for example to run blended
learning sessions or video conferencing.
The real time consumption of bandwidth by each college, and designated groups within each college, is
automatically monitored using freely available open source software (PFSense Firewall and CACTI), allowing
major users to be identified (Figure 4). Again using open source software (ntopand NAGIOS), any unplanned
excessive demands on the network can be rapidly recognised, and decisions are taken as to how respond
(Figure 5).
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Figure 4: Diagrams illustrating the use of CACTI to monitoring Bandwidth usage
Figure 5: Use of Nagios to Monitor Service Availability at the University
4. Discussion
The three very different health research and teaching organisations described in the above case studies share
a common ambition to take advantage of the opportunities provided by advances in the use of new
technology in education. Not only do they aim to use the technology to complement traditional teaching
methods in the delivery of courses to their own students, but to make such courses available to a much larger
audience via distance learning. Taken together they provide an interesting illustration of the trade-off between
availability of resources and freedom of action when attempting to establish e-learning courses on public
health and health research. Thus IIPHG has limited IT and human resources but, with just 12 faculty members,
considerable flexibility in the use of those resources and the potential for rapid innovation. The College of
Health Sciences has the equipment, staff and, very importantly, large volume of tried and tested course
materials to address much larger challenges but can only do so by navigating existing University protocols and
negotiating access to resources with colleagues who may have quite different priorities.
In large organisations there clearly has to be an established resource allocation policy, with clearly defined
limits on flexibility, if staff are to have confidence that their access will not be regularly disrupted to meet the
‘special needs’ of others. Allocation of resources is of course a very familiar problem to those working in the
health sector, and the problems of network allocation share some of the same characteristics. While a simple
‘equity of access for all’ principle may seem to be the obvious basis for policy, this could impose severe
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constraints on innovation and experimentation, which often tend to give rise to unpredictable demands for
additional resources at short notice.
The case studies reinforce the argument that a lack of suitably qualified, motivated and experienced personnel
is a common major barrier to the development of e-learning generally (Khan, et al., 2012), and in global health
education. This relates both to the systems professionals required to implement and maintain the necessary
hardware and software, and to the need for a teaching staff with the interest and aptitude required to design
e-learning materials and collaborate with technical staff in developing systems that are not only attractive and
easy to use but consistent with the highest educational standards. Again, close collaboration between teaching
and technical staff may be easier in smaller institutions if both sides are encouraged to see themselves as part
of a single team. In larger organisations there may be a very important role for intermediaries, either teachers
who have acquired technical expertise or IT staff with a willingness to explain technical issues in ways that can
be easily understood by teachers (Afshari, et al. , 2009; Nawaz, et al. , 2010).
Another common concern across the case studies is limited IT infrastructure and particularly bandwidth
availability (Hvorecký, et al., 2005; Okine, 2006). This has always been problematic but is becoming
increasingly so as expectations rise more rapidly than system improvements. Students now expect easy access
to everything the internet has to offer not only using the many desk-top computers made available in each
organisation but using laptops, mobile phones and tablet computers. Such technical challenges are important
considerations for organisations embarking on e-learning, as they may well impact on student overall
experience of public health courses (Atkins, et al., 2016), which can in turn impact on educational attainment
(Owston, Lupshenyuk and Wideman, 2011 ; Sowan and Jenkins, 2013).
Based on evidence from the case studies, online teaching is perfectly feasible where participants have access
to a local intranet based on a server that stores the required teaching materials and on which the LMS is run.
All three case studies mention downloading material from remote sites during periods when demands on the
internet are at a minimum, for example at night or during holiday periods, and storing it on a local server. This
apparently rational solution does have the problem that there is a risk of contravening copyright law, given
that many sights make material freely available for individual downloads but explicitly forbid their uploading
onto another site. Access to external sites can cause substantially greater problems, but it is the provision of
distance learning services to users outside of the network, either in formal learning hubs or accessing learning
materials using external wireless links that give rise to major difficulties. Since there are now a multitude of
valuable teaching resources on global health and research methods that are hosted on external sites,
arranging reasonably high quality access to such sites is also very important. Though direct comparisons of
network resources are notoriously difficult due to the multitude of factors affecting quality and speed, table 1
sets out some of the basic indicators, together with those for the UK research organisation of one of the
authors for comparison. This may suggest that smaller organisations can be at an advantage, with even a basic
communications package allowing a reasonable bandwidth allocation across multiple demands.
Table 1: Staff numbers and bandwidth
Organisation Academic Staff (A) Bandwidth (B) B/A
IIHMR 46 20Mbs 0.43
IIPHG 15 2Mbs 0.13
Makerere 1,477* 170Mbs 0.12
IDS UK 170 98Mbs 0.58
* Makerere Human Resource Directorate as at January 2014
Measures adopted to address the above issues include limiting access to a single device for a given user, using
dedicated firewalls, limiting the maximum size of any download at peak times, and blocking access to sites
such as YouTube during working hours. One issue raised by IIHMR, but with universal application, is the
difficulty of distinguishing ‘reasonable’ from ‘unreasonable’ internet access. Downloading of photographs,
PowerPoint presentations or videos, which may involve very large downloads, may be a perfectly reasonable
action if they enhance the teaching experience. There is no simple way, for example to distinguish between a
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YouTube video that is clearly for entertainment purposes, and one that is directly relevant to a given course,
without viewing the download.
5. Conclusions
As indicated by the above case studies, there is considerable enthusiasm for the idea of using new technology
both to enhance the experience of their own students and to make their courses available to a much wider
audience. To achieve their objectives they typically have to overcome major constraints in terms of hardware,
software and human resources and they face a continuing battle to meet the challenges of a rapidly evolving
technological environment which makes little allowance for those struggling to keep up with the latest
developments. Some issues can be addressed by the institutions themselves. Others, such as limited national
or regional infrastructure for broadband internet access need to be brought to the attention of policymakers
and thought leaders, making clear that this can pose serious barriers to the expansion of access to potentially
very valuable e-learning facilities for expanding global health research education. We recognise that the
findings from three purposively selected case studies should not be seen as representative of the diverse range
of academic and research bodies in resource-constrained environments. Our suggestion is that this research
can provide a starting point for further work to investigate other institutions and examine if they have similar
challenges and barriers to implementation.
Finally, it is particularly important that academic institutions in high income countries recognise the needs of
those in LMICs and support and encourage their counterparts in developing systems that are well adapted to
their specific needs and circumstances. Recent developments, for example the growth of ‘cloud computing’
(Armbrust, et al., 2009) and the promise of greater opportunities for sharing hardware and software resources,
could have important implications in terms of allowing easier entry to advanced e-learning engagement by less
privileged education institutions in LMICs, and thus contribute to global health capacity.
Acknowledgements
We thank the ICT department from Institute of Health and Management Research, Jaipur (India), Indian
Institute of Public Health Gandhinagar (India) and Makerere University, Uganda (Africa) for facilitating
preparation of the case studies.
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... Reviewed studies sampled 40,223 healthcare providers. The studies employed various research designs, including cross-sectional designs in the United Kingdom, Taiwan, and globally [15,38,60], experimental designs in the USA, India, Ghana, Italy, Belgium, and others [1,10,12,13,18,20,28], longitudinal designs in sub-Saharan Africa and Italy [14,45], mixed methods studies in Guinea, Ghana, China, Republic of Ireland, Northern Ireland, Australia, and Nigeria [7,11,17,22,36,41,42,51,58] qualitative designs in Ukraine, Malawi, South Africa, the USA, India, Uganda, and Rwanda [7,11,[23][24][25]40], and randomised controlled trials in the Netherlands, the UK, and Australia [9,16,27,31,32,44,56]. Thus, most of the reviewed studies were experimental designs (15) and mixed-method designs (11) (see details in ...
... Barriers to effective eLearning adoption among healthcare providers encompass a range of personal, systemic, and environmental factors. Personal factors include a lack of perceived need for eLearning [38], poor computer competence and literacy [7,23,25,41,42,45,60], absence of personal computers [7,10,24,41,45,60], financial constraints [8,36,60], low self-control [60], high family duties [60], and concerns regarding low knowledge retention after eLearning programmes [14,58]. ...
... Other barriers include time constraints [8,24,31,40], resistance to change [11], language barriers [25,40], dissatisfaction with eLearning content [11,31,58], heavy and conflicting content, and inadequate feedback within the eLearning environment [9,23]. ...
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... Where instructors are required to design on their own, Mtebe (2020) reported that they did not have enough skills and competencies to develop quality instruction, while some instructors also display a tendency to use an LMS as a passive repository (Gupta, et al., 2017). ...
... As noted by Khavugwi (2017), online teaching requires commitment, while faculty have a direct influence on student attitudes (Olasina, 2019). Gupta, et al. (2017) detailed requirements for suitably qualified and experienced staff but also referred to the need for motivated staff who are naturally interested in e-learning initiatives. Yakubu and Dasuki (2018) reported that information quality (effective teaching by trained instructors that will ensure relevance, comprehensibility, and accuracy) has the strongest influence on student attitudes toward the use of an LMS. ...
... Students ranked insufficient Internet connectivity as their key challenge in using an LMS (Mutisya and Makokha, 2016), which affects access time and makes it difficult to complete work (Qwabe and Khumalo, 2020). Interacting with rich media, such as videos, becomes problematic (Zozie and Chawinga, 2018;Gupta, et al., 2017), as do synchronous communications (Gupta et al., 2017). Students who live off-campus are also more affected than residential students, with the former recognised as having limited or no bandwidth (Gupta, et al., 2017;Gani and van den Berg, 2019). ...
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... Technological Factors also play a central role, as Afghanistan's unstable electricity supply, weak ICT infrastructure, and unreliable internet access pose significant challenges. These technological barriers hinder the ability of even the most enthusiastic faculty and students to engage in digital learning effectively, mirroring global issues in technologydriven education (Gupta et al., 2017). ...
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The transition to a post-conflict nation presents numerous challenges for higher education. This study explores the advantages and impediments of implementing digital learning in Afghan higher education institutions (HEIs). Digital learning in Afghan HEIs currently falls short of stakeholder expectations and requirements. Authorities and key stakeholders, however, have taken measures to address these issues and ensure seamless integration of digital learning into HEIs. Efforts have been made to promote digital learning and improve access to higher education for disadvantaged groups, which could expand educational opportunities and foster diversity, equity, and inclusion, particularly among girls in Afghanistan. Our research employed an interpretive field approach, conducting interviews with 102 participants across 12 Afghan universities—eight public and four privates—to examine the challenges and opportunities associated with digital learning initiatives and inclusive education in a post-conflict setting. We also recommended ways to improve digital learning and promote inclusive education in the country. Our findings provide recommendations for digital and policy strategies to enhance the digital learning experience and promote inclusive education in post-conflict nations. The experiences and lessons learned from Afghan HEIs offer valuable insights for developing more accessible, engaging, and effective online education models.
... Third, regional disparities affect the implementation and quality of One Health education. Institutions in low-and middle-income countries often face resource constraints that limit the availability and quality of One Health programs and practical learning opportunities [51,52]. In contrast, high-income countries have better resources to support comprehensive curricula and research. ...
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... According to [44], e-learning courses provide a flexible and versatile learning system that enables individual learners and organizations to tailor their training to fit their specific circumstances. Moreover, [45] declared that E-learning has become quite popular and appreciated among students all over the world. However, [14] demonstrated that although longdistance learning and e-learning offer numerous benefits, including increased accessibility and flexibility, there are still some challenges, such as the lack of face-to-face interactions and the need for a reliable internet connection and higher IT technology. ...
... Like clouds in the sky, the amount of resources in these "clouds" is infinite and can be accessed at any time. Access costs are also quite low [3]. The access method is also very convenient. ...
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The purpose is to solve the problems that the traditional teaching methods limit the openness and extension of the music classroom, the interaction between teachers and students, the environment of students’ autonomous learning, and the music teaching situation. Wireless local area networks, Bluetooth, and intelligent transmission channels based on specific frequency can replace wired audio transmission and are widely used in the digital music classroom. Moodle system is used to build a music teaching network system based on the analysis of previous studies and the existing music teaching network platform. The system combines with Convolutional Neural Network (CNN) structure based on cloud computing to effectively identify and create music scores. The system effectiveness is further proved by analyzing the learning effect of the students and teaching effect of teachers in the conservatory of music. The results show that the system makes the experience of teachers and students in the teaching system different from before, and students can freely choose the time and place of class. In addition, the teaching method is flexible, and the teaching methods and resources are real-time. Therefore, in the music teaching network course, it overcomes some shortcomings of the traditional teaching mode. The music class is open and flexible. Teachers and students can have more interactive behavior and realize the students’ self-study and music teaching environment. This exploration can provide a theoretical basis and practical experience for music-related teaching.
... Widely implemented by multinational corporations, ICT supports information transfer and knowledge management to remain competitive and facilitate workforce training (Huck et al., 2011;Matschke et al., 2012). The adoption of virtual training or web-based learning (WBL) for instruction in academic, government, and private sectors has become the fastest growing education modality and functions to mitigate traditional training barriers (Beinicke & Bipp, 2018;Gupta et al., 2017;Sinclair et al., 2016). The World Health Organization (WHO) has emphasized the integral role of ICT in healthcare systems in improving the delivery of care, supporting education and research, and monitoring public health (WHO, 2005). ...
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Nurses are the backbone of health assessments and key to safeguarding health services for people who are displaced and migrating. Training and dissemination of information among an international workforce requires innovative delivery methods that address the barriers of traditional in-person training. This quality improvement project endorsed web-based learning as a viable platform to disseminate information and support a standardized approach to professional development of nurses working in a complex and dynamic international healthcare setting.
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Background. Learning management systems (LMS) are indispensable teaching and learning tools in nursing education, and in recent years, LMS have become a cornerstone to support online learning, particularly during the COVID-19 pandemic. The South African (SA) e-education policy requires every teacher and learner in the education and training sector to be information and communication technology (ICT)-capable, and able to use ICTs confidently and creatively to help develop the skills and knowledge they need as lifelong learners to achieve their personal goals and be full participants in their global communities. Objective. To investigate postgraduate students’ experiences with learning management systems at a selected nursing education institution in KwaZulu-Natal Province, SA. Method. An exploratory, descriptive research design was used, and the whole population of 16 postgraduate nursing education students who were exposed to Moodle as a learning management system participated in the study. Qualitative data were collected through semi-structured interviews, followed by focus group discussions, with thematic analysis used to analyse data. Results. This was the first time that most participants had been exposed to an online learning course, and the experience made them feel empowered as it provided enabled reflection and deep learning. Participants indicated that the range of interactions and level of engagement determined the eventual level of knowledge constructed. The online facilitator played a central role in guiding and supporting students, and ensuring that they achieved the learning outcomes. The online learning benefits included increased socialisation, convenience and flexibility, asynchronicity and accessibility of learning material. The challenges were the lack of real-time response, financial cost and technical issues. Conclusion. An intense ICT orientation for students is recommended to ensure that they are informed of the requirements before starting the online course. The online facilitators must be more visible in the online space, participate more often in discussions and stimulate constructive dialogue.
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an INASP team of colleagues in Ghana, Kenya, Nigeria, Gemany and the UK, undertook a rapid study to explore how academics were innovating in digital learning. This enabled us to tell a new and important set of stories of how academics are quietly innovating, often below the radar and invisible to their colleagues and institutions. In the process these individuals are helping to foster new approaches to teaching and to provide better learning experiences for their students. Our report presents 26 stories and celebrates innovators in 15 universities across Ghana, Kenya and Nigeria. It examines what these stories can tell us about digital learning in these institutions, reflects on what drives academics to innovate, and explores what enables or hinders these new practices. The report goes on to offer a vision for digital teaching and learning, which emerged directly from the workshops, and a series of recommendations for academics, university leadership and national policy makers. You can download the final report here: Creating digital content and delivering digital learning in African universities You can also read this short piece in University World News through which we sought to share our findings with a wider audience: Innovative teaching is happening – often unsupported Finally, you can also access the full stories on our Medium site here: Digital Universities in Africa - Stories of innovation from educators in Ghana, Kenya and Nigeria
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Objective: Although the provision of e-learning (EL) training for healthcare workers (HCWs) and provider-to-HCW e-consultation (EC) is considered useful for health outcomes, research on their joint use is limited. This scoping review aimed to create an overview of what is currently known in the literature about the use and implementation of EC and EL by HCWs in LMICs and to answer the question of whether there is evidence of complementarity. Materials and methods: Scientific databases were searched and peer-reviewed papers were reviewed systematically according to predefined inclusion/exclusion criteria. Data were extracted including the study focus (EC/EL), year of publication, geographical location, target population, target disease(s) under study, type(s) of study outcomes, and article type. Results: A total of 3051 articles were retrieved and screened for eligibility, of which 96 were kept for analysis. Of these, only 3 addressed both EL and EC; 54 studies addressed EL; and 39 addressed EC. Most studies looked at gain in knowledge/skills usability, efficiency, competence, and satisfaction of HCW, or barriers/challenges to implementation. Descriptive studies focused on the application of EL or EC for targeting specific health conditions. Factors contributing to the success of EC or EL networks were institutional anchoring, multiple partnership, and capacity building of local experts. Conclusions: Our review found an important gap in the literature in relation to the complementary role of EL and EC for HCWs in LMICs evidenced by outcome measures. There is an important role for national and international academic institutions, learned medical societies, and networks to support regional experts in providing EL and EC for added value that will help the clinical performance of HCWs and improve health outcomes.
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Background Growing demand for Global Health (GH) training and the internationalisation of education requires innovative approaches to training. Blended learning (BL, a form of e-learning combining face-to-face or real-time interaction with computer-assisted learning) is a promising approach for increasing GH research capacity in low- to middle-income countries. Implementing BL, however, requires additional skills and efforts from lecturers. This paper explores lecturers’ views and experiences of delivering BL courses within the context of two north–south collaborative research capacity building projects, ARCADE HSSR and ARCADE RSDH. Design We used a qualitative approach to explore the experiences and perceptions of 11 lecturers involved in designing and delivering BL courses collaboratively across university campuses in four countries (South Africa, Uganda, India and Sweden). Data were collected using interviews in person or via Skype. Inductive qualitative content analysis was used. Results Participants reported that they felt BL increased access to learning opportunities and made training more flexible and convenient for adult learners, which were major motivations to engage in BL. However, despite eagerness to implement and experiment with BL courses, they lacked capacity and support, and found the task time consuming. They needed to make compromises between course objectives and available technological tools, in the context of poor Internet infrastructure. Conclusions BL courses have the potential to build bridges between low- and middle-income contexts and between lecturers and students to meet the demand for GH training. Lecturers were very motivated to try these approaches but encountered obstacles in implementing BL courses. Considerable investments are needed to implement BL and support lecturers in delivering courses.
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