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Paper—Current State of ICT in Healthcare Delivery in Developing Countries
Current State of ICT in Healthcare Delivery in
Developing Countries
https://doi.org/10.3991/ijoe.v15i08.10294
Adebayo Omotosho (*), Peace Ayegba
Landmark University, Omu-Aran, Nigeria
bayotosho@gmail.com
Justice Emuoyibofarhe
Ladoke Akintola University of Technology, Ogbomoso, Nigeria
Christoph Meinel
University of Potsdam, Potsdam, Germany
Abstract—Electronic health is one of the most popular applications of in-
formation and communication technologies and it has contributed immensely to
health delivery through the provision of quality health service and ubiquitous
access at a lower cost. Even though this mode of health service is increasingly
becoming known or used in developing nations, these countries are faced with a
myriad of challenges when implementing and deploying e-health services on
both small and large scale. It is estimated that the Africa population alone car-
ries the highest percentage of the world’s global diseases despite its certain lev-
el of e-health adoption. This paper aims at analyzing the progress so far and the
current state of e-health in developing countries, particularly Africa, and pro-
poses a framework for further improvement.
Keywords—E-health, developing countries, framework, ICT, healthcare.
1 Introduction
Individuals in poor and developing countries have the least access to health ser-
vices due to low financial resources, lack of infrastructure and other barriers in ac-
cessing the needed services [1, 2]. In addition, the dearth of competent health care
professionals and low health education has contributed to the need for a shift in para-
digm and innovative solutions in health workforce development. The popularity and
growth of the Internet and mobile wireless technologies have assisted in changing the
face of healthcare delivery and health education for health professionals in many
countries. There has been an increasing number of developed and developing coun-
tries with e-health strategies, and as of 2015, Bangladesh, Paraguay, Qatar, and
Rwanda were the most recent group of countries with official adoption of e-health
strategies out of the 73 countries with e-health adoption [3].
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However, the income of the populace generally affects individuals’ access to health
care services, and in the past, it has been recorded that only 12% of low income and
middle-income countries (LMIC) spend on health care services [4]. About 50%, 30%
and 14% of individuals in LMIC, middle-income countries and high-income countries
respectively pay for healthcare services themselves. According to the World Bank
income group, with regards to the source of funding of e-health; public, individual
donor, public-private partnership and private were identified as the main sources.
However, in the United States alone, between 1990 and 2007, the health assistance
funds have grown from $5.6 billion to $21.8 billion [5]. It is estimated that Africa
which has 11% of the entire world’s population carries 22% of the global diseases [6].
In South Africa, state healthcare is provided to about 40 million people (82%` of the
population) with about 9500 doctors, and private healthcare with 25,000 doctors serve
8.5 million people. Tanzania has a doctor-patient ratio of 1:20000 and Kenya, a doc-
tor-patient ratio of 1:16,000. In Nigeria with over 150 million people, a study carried
out by Nigeria Medical Association revealed a doctor-patient ratio of 1:4250 [7, 8].
Developing countries population is also among the highest in the world and the
demand for quality, affordable and accessible healthcare is high. Without the integra-
tion of technology into existing infrastructure, it may be impossible to meet the
healthcare need of the populace. Information and Communication Technologies (ICT)
have been described as a general-purpose technology (GPT) that can impact growth
and transform countries over a prolonged period of time, and like every other GPT
such as steam engine and electricity, it is characterized by pervasiveness, improve-
ment, and innovation [9]. In addition, ICT produces two other effects – network and
knowledge enrichment. A country intending to benefits from ICT revolution must
have a productive digital strategy. One of the many benefits of ICT enabled health
system is the ability to decrease patient’s data collection cost by about 71% [6]. E-
health is generally defined as the use of ICT for health, popular forms of e-health
include telemedicine, telehealth, m-Health, consumer health informatics, electronic
health records, healthcare information system [10,3]. E-health is becoming recogniza-
ble in Africa and a survey report by [11] indicated that South Africa, Kenya, and
Ghana have the most e-health and health informatics strategies implemented with
Kenya leading the market in digital health. Ethiopia is also seen to have one of the
most effective healthcare systems with health extension programs, the utilization of
telemedicine and mobile applications for promoting health care services.
For instance, in Africa, patients’ anamneses are mostly fragmented, disjointed and
distributed among several healthcare givers platforms which may be public or private
[12, 13, 14, 15]. This, however, constitutes a problem that limits completeness, shar-
ing and accessibility of information, most especially with public hospitals which are
generally non-ICT compliant. [16] Supported this claim in their report – that the use
of ICT is growing at a faster pace in private health organizations in developing coun-
tries than in public health organizations. Public healthcare in rural areas faces a short-
age of professional, patient’s noncompliance, and potential fraud which could be
alleviated with the widespread adoption of ICT in health care. E-health education and
awareness are also key factors, government and stakeholders must engage in pilot e-
health projects that could provide more evidence to support their investment and pro-
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mote widespread adoption. Lastly, e-health systems are capable of motivating and
improving patient’s engagement in their health care, and if e-health systems are de-
signed with the local context, target users’ needs and preference in mind, rather than
an isolated solution, e-health technology will add value to the patient and treatment
[17]. The paper aims at analyzing progress so far and the current state of e-health in
developing countries particularly Africa and propose a framework for further im-
provement.
2 Selected Existing Studies on E-health in Developing Countries
Chronologically Reviewed From 2010 to 2018
[18] Performed a qualitative and quantitative survey on the role of ICT in health
care services for developing countries. In their article search criteria, ‘e-health’ was
used interchangeably with the term ‘health information technology’. The search was
carried out in October 2009, using articles from Medline, Embase, Web of Science,
LILACS, Google Scholar search, Rhino, and Social Sci Citation index databases. In
the exploration, a total of 2043 citations and 55 articles (15 qualitative and 40 quanti-
tative) were used. Their evaluation results suggested the use of more robust e-health
practices in developing countries. It was also noted that personal digital assistants and
mobile devices boost up the efficiency of e-health practices. [19] Performed an exten-
sive review of existing e-health frameworks used in the development and deployment
of e-health technologies so as to identify aspects of their use that influence their suc-
cess. The database sources used were PubMed, Science Direct, Picarta, Google
Scholar, and Web of Knowledge, and 44 journals were selected for the review out of
the 60 articles acquired. Results indicated that the Web 2.0 technologies which de-
mand a more stakeholder-driven approach are outside the current framework's scope.
Their results were then used to propose a holistic approach in the development of e-
health technologies which combines health technology theories and business models
that act as a road map in the impact of e-health technologies.
Telemedicine is another widely favored form of e-health and it involves the medi-
cal information interchange between different parties situated at separate geographical
areas through the use of a telecommunication link. The challenges in the implementa-
tion of the first telemedicine program in Ethiopia that ran between 2004 and 2006
were analyzed by [20]. 85% of Ethiopia’s population live in remote areas and do not
have access to adequate health care facilities. The first trial was carried out in 10
health care sites where a telemedicine software from wireless distribution system
technologies was implemented. The software had a lot of technical difficulties and
Telemed-ETH, another telemedicine software was developed as an improvement.
Results of the interviews from participants showed about 70% faced connectivity
problems and 61% reported that the system was disorganized. Also, it was found that
25% of the participants indicated interest in scaling up telemedicine in their universi-
ties. It was concluded that e-health and telemedicine could contribute immensely to
the growth of health coverage in Ethiopia. The project was funded by the International
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Telecommunication Union-United Nations Economic Commission for Africa and
infodev.
[21] Published a work that described the level of satisfaction of Brazilian physi-
cians using an implemented EHR. A cross-sectional questionnaire survey was carried
out with a total of 111 subjects, although only 99 physicians responded. 81.4% of the
respondents believed the EHR response time was not as fast as expected, 86.7% re-
ported that the system had technical failures and 35.1% complained about insufficient
computers at their health clinics. The final result showed that only 2% of the respond-
ents were well satisfied with the EHR, 50.5% were partly satisfied and 47.5% were
dissatisfied. In addition, in their conclusion, it was documented that structural issues
and lack of classical functions like clinical reminders were some challenges faced by
the EHR system, among other complaints. [22] carried out a survey on the adoption of
the electronic clinical decision support system (eCDSS) for maternal care in Tanzania
and Ghana between 2011 and 2013. A total of 282 health workers participated in the
survey and the majority of them responded positively. 71% of 3,798 patients and 59%
of 24, 204 patients were managed in Tanzania and Ghana respectively by the eCDSS
over the space of two years. It was concluded that the system was a viable tool to be
implemented in rural areas as it is user-friendly and useful.
[23] Performed a review on the progress of mHealth - the use of mobile device
technology for health-related purposes - in Sub-Saharan Africa. The study was re-
stricted to articles published within a 10-year period before March 16, 2013, with the
search keyword “mHealth” in PubMed. From a total of the 21 articles reviewed, it
was found that medication adherence, health worker communication, emergency, and
disaster response, as well as health education, were some of the improvements made
by mHealth in Sub-Saharan Africa. It was also concluded that more research regard-
ing the cost-effectiveness of mHealth and e-health technologies in Africa is still re-
quired. [24] carried out a methodical review on the impact of e-health through a litera-
ture search in PubMed, MEDLINE, EBSCO Academic Complete, ScienceDirect,
IEEE, AIS e-library, CINAHL, and the ACM databases, with no restriction on the
search date. Out of the 265 articles obtained, only 13 articles met the inclusion criteria
- a qualitative empirical study in the utilization and influence of e-health technology
for community health facilities (CHF) in a developing country. The method used in
the majority of these 13 articles were surveys done in Africa. In their finding, the
Electronic Medical Record system was the most widely recognized e-health technolo-
gy tool identified that focused on the quality of healthcare. The limited number of
articles included suggested a low rate of diffusion, in developing countries, of e-health
in community-based facilities. Results of their review also showed that the majority of
research focuses on the effectiveness of these technologies and little on equity and
efficiency.
[25] Performed a cross-sectional study to investigate users’ attitudes to the use of
an interactive voice system (IVR) in seeking healthcare services in Ghana. Forty par-
ticipants were involved in the focus group discussions (21 female and 19 male) with
an age range between 18 and 59 years. Most of the participants showed interest in the
use of the IVR system for health care services especially with the general use of mo-
bile phones and a toll-free number for the system was recommended. [26] examined
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the factors that influence the adoption and utilization of e-health facilities in Bangla-
desh, South East Asia. A survey of patients was carried out with a questionnaire
where the average age of the participants is above 30 years of age. The study exam-
ined patients’ behavioral intent in the adoption of e-health using an extended technol-
ogy acceptance model (TAM). Results showed that the perceived ease of use (PEU),
perceived usefulness and trust are important prerequisites for patients’ adoption of e-
health, whereas privacy has no effect on the use of e-health in Bangladesh. It was
also found that gender strongly influences the use of e-health with a stronger PEU
influence in males.
Telemedicine, a subset of e-health, is the least likely to be administered in develop-
ing countries due to poor connectivity and inadequate infrastructure according to [27],
who reviewed 228 articles in Scopus database to reveal current telemedicine activities
in Africa. It was concluded that tele-education is the most widely recognized and
effective application e-health in Africa, and therefore telemedicine has great poten-
tials to thrive in Africa. [28] focused on the benefits and challenges in the implemen-
tation of e-health systems for perinatal and maternal health care in Tanzania. Mobile
teleconsultation platforms, audio teleconferencing model and online e-learning sys-
tems were implemented in ten upgraded health care centers, including one regional
hospital, and four rural district hospitals. Thirty-three teleconferences were held and
there were forty healthcare participants, including assistant medical officers and mid-
wives. A total of thirty-eight emergency teleconsultations were also attended to by
consultant obstetricians in 2015 and 87% of the patients were successfully managed.
On the e-learning platform, out of forty registered users, twenty users were inter-
viewed after six months of participation and 65% found the system easy to use, 15%
found it difficult and 20% were neutral. These results indicate great potentials for the
progress of e-health systems in Tanzania. Their study, however, does not adequately
evaluate the impact of these platforms on health outcomes.
[29] Examined the forms of e-health and information system theories to understand
the sustainability and implementation of e-health particularly in developing countries.
Some of the theories include the actor-network theory (ANT), technology acceptance
model (TAM) and the technology organization and environmental framework (TOE).
Based on their findings, some of the issues that affect the development of e-health
identified include, e-health standards, ICT and health policies, ICT competence, e-
legislation, and e-health infrastructure. [30] Examined the diffusion of telemedicine
practices in Ghana, and like any other developing countries in Africa, health centers
and facilities in Ghana are not enough to be accessible by everyone. However, e-
health in Ghana has shown great promises with the recent development of the Novar-
tis telemedicine project in Bonasso. The foundation made provision for mobile devic-
es for the propagation of telemedicine and teleconsultation services to medical per-
sonnel. Eight cases of e-health and telemedicine practices in Ghana were outlined and
these cases showed the use of telemedicine, e-health, teleradiology, teledermatology,
teleconsultation, telecommunication, telemedicine and prenatal care implementation
in Ghana. Using e-health systems, it was also shown that the new HIV infections in
Ghana reduced by 53% from 2001 – 2014. This result shows that with adequate sup-
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port from the government and funding, telemedicine will influence healthcare posi-
tively in Ghana and other developing countries.
[31] Investigated the ICT performance of the 10-member states of the Association
of Southeast Asian Nations (ASEAN) countries, comprising of developing countries
and least developed countries of the world. It was found that ICT progress is not even-
ly distributed and the author proposed that monitoring of the progress of member
countries on ICT digitization needs improvement. Another important finding showed
that in order to measure the adoption of mobile technologies, mobile phones penetra-
tions are a no longer meaningful indicator in this region. The obstacles in transition-
ing health systems in LMIC were identified in [32]. Based on a study of Bangladesh
and China pluralistic health sectors with relatively underdeveloped institutional ar-
rangements, it was reported that despite the significant economic differences between
the countries, both countries have in common, high mobile phone adoption, excellent
ICT sector and supportive government which has helped in their e-health strategies.
The authors advocated for the support, contribution and influence of government and
stakeholders in driving a successful ICT in health care to increase access to safe, ef-
fective, affordable health care to the poor. Factors responsible for ICT diffusion were
also identified, these include time taken to build a partnership between private and
public sectors and lack of a supportive regulatory environment.
[33] Presented a project called EXTEND which aims at addressing issues affecting
the use of e-health tools in Nigeria. The protocols used for this project is mixed-
method - non-randomized cluster trial of the use of e-health tools. The project at-
tempts to evaluate e-health applications in Kano, Ondo, and Abuja. Then two applica-
tions called the Video Training Application (VTR) and the Clinical patient application
toolkit (CliniPAK) were successfully implemented between 2016 and 2017 in 126
primary health care facilities (PHC) in all three states. Health workers were also
trained to make use of these applications. The project is said to comprise three phases,
a baseline within 3 months, a 12-month midline assessment and end line evaluation in
24 months. The project though not yet completed is expected to generate new
knowledge to improve the quality and efficiency of e-health systems. [34] Reviewed
literature that explored the challenges of e-health in LMIC. Four African countries,
Rwanda, Kenya, Malawi, and Uganda were explored in their study. Some of the chal-
lenges of e-health noted in this region include little participation in e-health develop-
ment, lack of a formal standardization process, unregulated penetration of e-health
systems and delayed e-health standardization efforts. Their results also showed that
LMIC’s participation in seven e-health standard development organizations is a low
23.3%, hence the necessity to develop standards that meet every country’s interopera-
bility needs, especially in resource-constrained environments.
[35] Focused their study on e-health applications in the Middle East and North Af-
rica. The paper relayed the importance of the Middle East and North African Health
Informatics Association - an NGO that focuses on health informatics. Instances of e-
health implementations in major countries of this region were highlighted, In Egypt,
several companies have implemented thriving e-health projects like mHealth and
pharmacy management systems. In Jordan, an electronic medical record system called
Hakeem has been implemented nationwide. In Morocco, the ministry of health tele-
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medicine initiatives is in progress. In Palestine, a project implemented between 2008
and 2013 procured the use of Avicenna, the first EHR system, though the system
lacked interoperability. In Sudan, the first National Telemedicine Network was estab-
lished in 2007. In Tunisia, there is the establishment of Tunisian Society for e-health
and Telemedicine in 2000 whose purpose is to advance the development of digital
health, and in the UAE, there is the implementation of electronic medical record
adoption model as well as a tool to unify medical records. [36] Performed research
similar to [26], but emphasized on rural end-users’ acceptance of e-health in
Bheramara subdistrict, Bangladesh. The authors pointed out the existence of a porta-
ble health clinic (PHC) service that has served about 41,240 rural patients in different
remote locations.
In their methodology, a survey was performed between June and July 2016 with
292 rural participants. The results of their study showed that the social reference was
the most significant influential variable followed by, attitude to the system, access to
cell phones, then perceived the effectiveness of the system. [37] described the imple-
mentation of a new OpenMRS- based system called AfyaEHMS in Kenya. This sys-
tem was implemented in 320 health facilities in Machakoscounty, Kenya. Some of the
key challenges of the system discussed include, use of scalable infrastructure, stake-
holder engagement, harnessing local talent in the development of the system, system
integration, and large project scope.
There has also been a low diffusion of e-health systems in Zimbabwe according to
[38] who performed a qualitative study on the factors affecting the implementation of
e-health in their public hospitals. Semi-structured interviews were carried out from
twenty medical doctors in three central and seven provincial hospitals.
These interviewed doctors had prior experiences using EHR, telemedicine and Dis-
trict hospital information systems (DHIS). Inadequate e-health infrastructures, lack of
ICT skills by medical doctors, resistance to change and government policies were
some of the factors revealed to be limiting e-health diffusion.
A three-way relation that exists between e-health, health care professionals and pa-
tients in Sub Saharan Africa was considered in [39] to ascertain whether patients’ e-
health preference can influence health care professionals’ decision to use technology
in their clinical practice.
The interview was employed, as well as a Q-methodology with an adopted mixed-
methodology approach that involves participants arranging 46 statements with respect
to how they influenced their clinical practice. It was found that patients influence the
clinical choice of health care professionals. Table 1 shows the state and visibility of
different forms of e-health in some developing countries.
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Table 1. Varieties of e-health application in developing countries
Author
Country
E-health type
Specific E-health initiative
E-health
Strategy
[27]
South Africa
Telemedicine
Video conferencing for e-
health
YES
[40]
Ghana, Rwanda, Kenya,
South Africa, Ghana,
Lesotho, Zimbabwe,
Uganda, Tanzania,
Mozambique
Electronic medical
record (EMR)
OpenMRS
YES
[21]
Brazil
EHR
Unspecified
YES
[41]
Botswana
mHealth
Not specified
[22]
Tanzania, Ghana
Electronic clinical
decision support
system
eCDSS
YES
[42]
Morocco, Tunisia
Health Management
Information System
(HMIS),
Electronic Medical
Record,
Hospital Infor-
mation System,
Teleservices
Unspecified
YES
[25, 30]
Ghana
mHealth, Telemedi-
cine
Mobile interactive voice
response system (IVR)
YES
[43]
Uganda
mHealth, Electronic
Medical Record
Matibabu application, mTrack,
District health management
system (DHIS2)
YES
[33, 30]
Nigeria
Electronic Health
Record, Telemedi-
cine
Clinical patient administrative
kit (Clinipak), Video Training
application (VTR),
VSee telemedicine kit
(All-purpose medical infor-
mation system)
APMIS
NO
[20, 44]
Ethiopia
Telemedicine,
mHealth
Telemed-ETH, Project Orchid
mHealth platform
YES
[29, 45, 37]
Kenya
EMR, EHR, Health
Information system,
Electronic health
management system
System
DHIS2, KenyaEMR, Interna-
tional quality care health
management information
system (IQCHM), AfyaEHMS
YES
[37]
South Africa, Zambia,
Uganda,
Jamaica
EMR, Electronic
Health Record
Bahmni, GnuHealth
YES
[36]
Bangladesh
Telehealth
Portable Health Clinic (PHC)
YES
3 Deduction and Proposed Framework
Some of the major challenges of e-health in developing countries identified in this
work include – lack of necessary infrastructure, theoretically designed intervention,
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low awareness, poor funding, unregulated penetration of e-health technologies, lack
of formal standardization, lack of integrated and accessible health system, bureaucra-
cy of the ministry of health on utilization of e-health, sustainability of health systems,
lack of qualified personnel, lack of globally interconnected health system technolo-
gies, cost-benefit, and security and privacy. Based on the reviewed works, e-health
visibility in Africa and other developing counties of the world is becoming noticeable,
however, there are still multifarious hurdles to be crossed and framework to further
the expansion is shown in Figure 1. Some of the important components of this frame-
work are discussed.
3.1 Funding
Funds are required to adopt innovations locally, for testing, organizing meetings
with potential users, to pay teams involved in the project and integrating these tech-
nologies in health operations. Most developing countries lack the necessary financial
strength to properly fund and implement e-health strategies. Many healthcare innova-
tors struggle to fund their innovations and proposed e-health technology especially
during the structural implementation.
Nevertheless, the majority of health funds are from insurance packages, invest-
ments from private parties and other patients (or clients). However, besides providing
special allocation for e-health financing in the national budget, the government can
increase funding sources by partnering with local and international companies and
bodies who have an interest in health.
Also, due to the high demand for standard quality of wellbeing, units can be creat-
ed as arms of the government to take up this challenge. [46] Suggested several financ-
ing opportunities for e-health investment that involved mixed financing arrangements
from public-private partnerships, private ICT vendors, public health vendors, public
health service provider organizations (HPOs) as well as third-party payers. These
investors are advised to invest in effective, comprehensive financing packages that
include long term recurring expenses.
Some additional sources of funding in forms of donations and loans suggested by
[47] include the World Bank, United Nations development programme (UNDP), Afri-
can development bank (ADB), the World health organization (WHO), United States
agency for international development (USAID), Islamic development bank (IDB),
Japan international cooperation agency (JAICA) and individual organizations like the
Gates Foundation.
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.
Fig. 1. A proposed framework for e-health sustainability
3.2 Infrastructural facilities
In the setup of e-health technologies, infrastructure – which are unevenly distribut-
ed - are major necessities in the success of e-health application. A convenient working
environment, Internet facilities, and communication systems can help to improve the
performance and productivity of health care workers using electronic facilities. A high
percentage of people in developing countries live in rural areas and there are structur-
al limitations in physically implementing e-health technologies. This implies that
more basic facilities will be procured although, in the long run, the return on invest-
ment is expected to be high. Keeping in mind, that the hardware acquisition and
maintenance in resource-constrained countries is very difficult and a few human re-
sources are available to maintain these technologies, rather than starting from the
scratch and incurring high setup cost, the scattered existing public and private innova-
tive e-health facilities and solutions that are working can be upgraded and easily
funded. Infrastructure can be donated and build operate and transfer (BOT) can be
encouraged in order to ensure fast resources.
3.3 Qualified E-health professional and training
Work experience and training sessions in e-health is needed for integrating e-health
initiatives into already existing healthcare services in developing countries. Since e-
health solutions are not at an advanced stage in the majority of these nations,
healthcare professionals and their patients expect easy usage and navigation of health
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technologies in order to achieve the required functionality. In addition, complexity
factors can occur when health professionals are unable to adequately master the sys-
tem. Such complexities include speed, connectivity issues, unplanned downtime and
the overall reliability of the system. Continued education on e-health inventions is
therefore essential.
These training should be designed to equip healthcare professionals in the use and
management of e-health systems. Major in-house training on e-health is usually car-
ried out in developed countries but less in developing countries. Although e-health
systems are expected to be extremely user-friendly, technical assistance, and guides
for the use of the systems are to be provided. Training on the use of social media and
health systems can also improve the potential benefits of e-health.
[48] Suggested training and e-health education for hospital staff and health care
professionals so they can visualize the benefits of e-health solutions and in turn, push
the success of these innovations. Also, the study proposes a model involving the use
of open source e-health software, development, and improvement of infrastructures by
the government and the establishment of documented e-health policies that support
the growth of e-health education. [49] Emphasized the need for an increase in e-health
awareness and sensitizations through seminars and training workshops for health
professionals as well as an increase in electronic communications. Also, developing
guidance on the use of the technologies, medical device labeling and event reporting
systems for the devices are recommended to improve usability and effectiveness in
developing countries.
3.4 Evidence-based evaluations
The growth of e-health adoption can be accelerated with the provision of reliable
evidence provided through evaluation of the e-health technologies implemented and
outcome on health. This could, in turn, facilitates the trustworthiness and reliability of
the intervention. Evaluations are expected to focus on the success or failure of e-
health and considerably fosters the long-term sustainability of e-health. Developing
countries need to have a framework in place where it is possible to access the impact
of e-health and this can serve as a catalyst to further investment.
[50] Proposed an iterative approach (involving users in all stages of the develop-
ment of the technologies), formal and usage over time evaluations techniques. Some
mixed methods that involve the use of questionnaires, scenario-based evaluations,
usability testing, and logging and video recording of sessions are suggested as well.
[51] Also suggested two evaluation techniques, cost-benefit analysis (CBA) and cost-
effectiveness analysis (CEA). The CBA values the health outcome and benefits in
monetary terms and the CEA identifies what benefits can be realized at a lower cost.
3.5 Open E-health standard and national health policy
The various fundamentals of e-health standards are to be set out as a plan of action
in the delivery of health services. Countries with set out e-health policies have better
health services and usually attract public funding. These policies guide the e-health
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programmes, foster strategic large-scale implementation and address the contributions
of e-health to health objectives. Developing countries need regulations and standards
that ensure quality, safety, and reliability of health applications. Mobile e-health ap-
plications particularly require privacy policies which may vary in different countries
thereby affecting their scalability. Creating the e-health national standards streamlines
healthcare causing a more efficient e-health system. The monopoly of health facilities
can also limit e-health coverage therefore, an open standard will also ensure that
genuine fragmented systems in the market can be reconfigured to connect, conform
and interoperate with national e-health facilities. [52] Recommended that the govern-
ment provide policies and regulations that outline the standards and criteria that na-
tional e-Health strategies must meet to be certified. Trained health care professionals
should be monitored through continuous professional developments and their skills
should be tested through examinable curriculums. They also highlighted the need for
a regulatory body and subcommittee to examine e-health interventions with national
awareness. It is also advised that there should be the implementation of regulated
compulsory use of e-health systems policies at all times.
3.6 Global connectivity to local, regional and international stakeholders
Collaborative efforts and communication between diverse stakeholders can in-
crease the creation of innovative approaches in solving e-health challenges in devel-
oping countries. These stakeholders include the ministries of health and finance, pub-
lic and private healthcare institutions, research organizations, professional bodies, and
local and international partners. Their commitment is essential to the development of
health-workforce and health care coverage. Global connectivity has been proven to
work in developed countries and some developing regions like the ASEAN have
started adopting this. Neighboring countries in Africa can also collaborate and partner
on cross border access of e-health infrastructure. This will help to improve the ubiqui-
tous healthcare process at a low cost.
3.7 Multilingual framework
E-health services provided to citizens in the language they speak will encourage
the adoption of the e-health initiative. Technologies that provide multilingual support
are more engaging and user-friendly, thereby promoting understanding and connectiv-
ity to both health staff and patients. A national policy that promotes linguistic diversi-
ty and multilingual e-health content will enhance e-health adoption. This has been
reported to be one of the least explored features of e-health despite being capable of
raising the level of awareness and adoption in developing countries.
4 Conclusion
Some of the challenges faced by e-health strategies in Africa include insufficient
skilled health care workers, lack of health information systems, shortage of drugs,
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inadequate public information and financial constraints. ICT has proven to be very
useful in several sectors of the world’s economy like government, manufacturing,
banking and so on. The use of computers and technologies have helped to improve
productivity, efficiency, coverage, and availability of various services at reduced cost.
ICT in health, also known as e-health, is also becoming one of the widely recognized
areas of application of technologies in the modern world. Transitioning healthcare
systems in Africa and other developing countries, where budget and funds for health
is very low, is challenging. In this work, we carried out a review of some e-health
systems and strategies in Africa and some other developing countries. And it was
found, that though e-health and other related technologies are gaining some momen-
tum in developing countries, there is still need for further improvement. We, there-
fore, proposed a framework for sustainable e-health system based on the gaps identi-
fied in the reviewed works. This work is expected to contribute to the development of
long-term e-health implementation in developing countries.
5 References
[1] Peters, D. H., Garg, A., Bloom, G., Walker, D. G., Brieger, W. R., & Rahman, M. H.
(2008). Poverty and access to health care in developing countries. Annals of the New York
Academy of Sciences, 1136(1): 161-171 https://doi.org/10.1196/annals.1425.011
[2] Omotosho, A., Emuoyibofarhe, J., Ayegba, P. & Meinel, C. (2019). E-Prescription in Ni-
geria: A Survey. Journal of Global Pharma Technology, 10(12S): 58 - 64
[3] World Health Organization (2016). Global Diffusion of eHealth: Making Universal Health
Coverage Achievable. Report of the Third Global Survey on eHealth. Geneva, Switzer-
land.
[4] Sen, A. (1992). Inequality Reexamined. Cambridge, Mass: Harvard University Press.
[5] Ravishankar, N., Gubbins, P., Cooley, R. J., Leach-Kemon, K., Michaud, C. M., Jamison,
D. T., & Murray, C. J. (2009). Financing of global health: tracking development assistance
for health from 1990 to 2007. The Lancet, 373(9681): 2113-2124 https://doi.org/10.1016/
s0140-6736(09)60881-3
[6] E-transform Africa (2012), ICTs for health in Africa. Available at
http://siteresources.worldbank.org/EXTINFORMATIONANDCOMMUNICATIONANDT
ECHNOLOGIES/Resources/282822-1346223280837/Health.pdf
[7] The Sun (2017), Nigeria’s poor healthcare access ranking. Available at
https://www.sunnewsonline.com/nigerias-poor-healthcare-access-ranking/
[8] Olawale G. &Orogun G. (2017). One doctor still attends to 6,000 patients in Nigeria-Don.
Available at https://www.vanguardngr.com/2017/01/one-doctor-still-attends-6000-
patients-nigeria-don/
[9] Bresnahan, T. F., &Trajtenberg, M. (1995). General purpose technologies ‘Engines of
growth’? Journal of econometrics, 65(1): 83-108 https://doi.org/10.1016/0304-4076(94)
01598-t
[10] Dinya E. & Toth T. (2013), Health Informatics: eHEALTH and TELEMEDICINE, Presen-
tation, Semmelweis University.
[11] Frost & Sullivan (2016). Enabling eHealth technology in South Africa, Kenya & Ghana:
Accelerating healthcare with mHealth, Healthcare IT and Telemedicine. Available at:
http://www.frost.com/sublib/display-report.do?
iJOE ‒ Vol. 15, No. 8, 2019
103
Paper—Current State of ICT in Healthcare Delivery in Developing Countries
[12] Omotosho, A., Asani, E. O, Ogundokun, R.O, Ananti E. C., &Adegun A. (2018). A Neuro-
Fuzzy Based System for the Classification of Cells as Cancerous or Non-Cancerous. Inter-
national Journal of Medical Research & Health Sciences, 7(5):155-166
[13] Omotosho, A., Emuoyibofarhe, J., & Meinel, C. (2017). Ensuring patients’ privacy in
acryptographic-based-ehr using bio-cryptography. International Journal of Electronic
Healthcare (IJEH), 9(4): 227 - 254 https://doi.org/10.1504/ijeh.2017.085800
[14] Omotosho, A., Asanga, U., &Fakorede, A. (2017). Electronic Prescription System for Pe-
diatricians. European Scientific Journal, 13(18): 426 – 437 https://doi.org/10.19044/esj.
2017.v13n18p426
[15] Omotosho, A., Adegbola, O., &Adebo, A. (2016). A Patient-Based Hospital Referral Deci-
sion Support System. International Journal of Computer Application, 115(10): 38 – 43
https://doi.org/10.5120/ijca2016912459
[16] Qureshi, N. A., Kundi, G. M., Qureshi, Q. A., Akhtar, R., & Hussain, L. (2015). An inves-
tigation into the adoption and use issues of E-health in public sector hospitals of develop-
ing countries. Mediterranean Journal of Medical Sciences, 2(1): 23 – 36
[17] Kip, H., Bouman, Y. H., Kelders, S. M., & van Gemert-Pijnen, L. J. (2018). eHealth in
treatment of Offenders in Forensic mental Health: A Review of the current State. Frontiers
in psychiatry, 9(42): 1 - 19 https://doi.org/10.3389/fpsyt.2018.00042
[18] Blaya, J. A., Fraser, H. S., & Holt, B. (2010). E-health technologies show promise in de-
veloping countries. Health Affairs, 29(2): 244-251 https://doi.org/10.1377/hlthaff.2009.
0894
[19] Gemert-Pijnen, J. E., Nijland, N., van Limburg, M., Ossebaard, H. C., Kelders, S. M., Ey-
senbach, G., & Seydel, E. R. (2011). A holistic framework to improve the uptake and im-
pact of eHealth technologies. Journal of medical Internet research, 13(4). https://doi.
org/10.2196/jmir.1672
[20] Shiferaw, F., & Zolfo, M. (2012). The role of information communication technology
(ICT) towards universal health coverage: the first steps of a telemedicine project in Ethio-
pia. Global health action, 5(1): 15638 https://doi.org/10.3402/gha.v5i0.15638
[21] Holanda, A. A., Do Carmo e Sá, H. L. D. C., Vieira, A. P. G. F., &Catrib, A. M. F. (2012).
Use and satisfaction with electronic health record by primary care physicians in a health
district in Brazil. Journal of medical systems, 36(5): 3141-3149 https://doi.org/10.1007/
s10916-011-9801-3
[22] Sukums, F. K. (2016). Implementation of an electronic clinical decision support system for
maternal care in rural primary health care facilities in Ghana and Tanzania: Assessment of
its adoption and usability.
[23] Betjeman, T. J., Soghoian, S. E., & Foran, M. P. (2013). mHealth in sub-Saharan Africa.
International journal of telemedicine and applications. https://doi.org/10.1155/2013/
482324
[24] Cohen, J. F., Coleman, E., & Abrahams, L. (2015, May). Use and Impacts of E-health
Within Community Health Facilities in Developing Countries: A Systematic Literature
Review. In ECIS 2015 Completed Research Papers. Paper 33.
[25] Brinkel, J., Dako-Gyeke, P., Krämer, A., May, J., &Fobil, J. N. (2017). An investigation of
users' attitudes, requirements and willingness to use mobile phone-based interactive voice
response systems for seeking healthcare in Ghana: a qualitative study. public health, 144:
125-133 https://doi.org/10.1016/j.puhe.2016.11.017
[26] Hoque, M. R., Bao, Y., & Sorwar, G. (2017). Investigating factors influencing the adop-
tion of e-Health in developing countries: A patient’s perspective. Informatics for Health
and Social Care, 42(1): 1-17 https://doi.org/10.3109/17538157.2015.1075541
104
http://www.i-joe.org
Paper—Current State of ICT in Healthcare Delivery in Developing Countries
[27] Mars, M. (2013). Telemedicine and advances in urban and rural healthcare delivery in Af-
rica. Progress in cardiovascular diseases, 56(3): 326-335 https://doi.org/10.1016/j.
pcad.2013.10.006
[28] Nyamtema, A., Mwakatundu, N., Dominico, S., Kasanga, M., Jamadini, F., Maokola, K.,
Mawala, D., Abel, Z., & Van Roosmalen, J. (2017). Introducing eHealth strategies to en-
hance maternal and perinatal health care in rural Tanzania. Maternal health, neonatology
and perinatology, 3(1): 3 https://doi.org/10.1186/s40748-017-0042-4
[29] Boore, C., James, N. M., &Iraki, X. N. (2017). Strategic issues in e-Health implementation
in developing countries: The Kenyan healthcare sector. Global Scientific Journals, 5(7): 50
- 62
[30] Ekanoye, F., Ayeni, F., Olokunde, T., Nina, V., Donalds, C., &Mbarika, V. (2017). Tele-
medicine Diffusion in a Developing Country: A Case of Nigeria. Science Journal of Public
Health, 5(4): 341 - 346
[31] Vu, K. M. (2017). ICT diffusion and production in ASEAN countries: Patterns, perfor-
mance, and policy directions. Telecommunications Policy, 41(10): 962-977 https://doi.
org/10.1016/j.telpol.2017.04.005
[32] Bloom, G., Berdou, E., Standing, H., Guo, Z., &Labrique, A. (2017). ICTs and the chal-
lenge of health system transition in low and middle-income countries. Globalization and
health, 13(1): 56 https://doi.org/10.1186/s12992-017-0276-y
[33] Ebenso, B., Allsop, M. J., Okusanya, B., Akaba, G., Tukur, J., Okunade, K., Akeju, D.,
Ajepe, A., Dirisu, O., Yalma, R., Sadeeq, A. I., Okuzu, O., Ors, T., Jagger, T., Hicks, J.P.,
Mirzoev T. & Newell, J.N. (2018). Impact of using eHealth tools to extend health services
to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial. BMJ
open, 8(10): e022174 https://doi.org/10.1136/bmjopen-2018-022174
[34] Alunyu, A. E., & Nabukenya, J. (2018). A Conceptual Model for Adaptation of eHealth
Standards by Low and Middle-Income Countries. Journal of Health Informatics in Africa,
5(2).
[35] Al-Shorbaji, N., Househ, M., Taweel, A., Alanizi, A., Mohammed, B. O., Abazae, H.,
Bawadif,H., Rasulyg,H., Alyafeih, K., Luquei, L.F., Shoumanj, M., El-Hassank, O., Hus-
seinl, R., Alshammarim, R., Mandiln, S., Shoumanj, S., Taherio, S., Emaraj, T., Dalhemp,
W., Al-Hamdanq, Z., Serhierr, Z. (2018). Middle East and North African Health Informat-
ics Association (MENAHIA): Building Sustainable Collaboration. Yearbook of medical
informatics. https://doi.org/10.1055/s-0038-1641207
[36] Hossain, N., Sampa, M. B., Yokota, F., Fukuda, A., & Ahmed, A. (2018). Factors Affect-
ing Rural Patients' Primary Compliance with e-Prescription: A Developing Country Per-
spective. Telemedicine and e-Health. https://doi.org/10.1089/tmj.2018.0081
[37] Paton, C. and Muinga, N. (2018). Electronic Health Records: a case study from Kenya.
Pathways for Prosperity Commission Background Paper Series; no. 12. Oxford, United
Kingdom.
[38] Furusa, S.S. & Coleman, A., 2018, ‘Factors influencing e-health implementation by medi-
cal doctors in public hospitals in Zimbabwe’. South African Journal of Information Man-
agement, 20(1): a928. https://doi.org/10.4102/sajim.v20i1.928
[39] Ladan, M. A., Wharrad, H., & Windle, R. (2018). Uncovering a tripartite relationship be-
tween patient, eHealth and healthcare professionals.
[40] Gerber, T., Olazabal, V., Brown, K., &Pablos-Mendez, A. (2010). An agenda for action on
global e-health. Health affairs, 29(2): 233-236 https://doi.org/10.1377/hlthaff.2009.0934
[41] Mauco, K. L., Scott, R. E., & Mars, M. (2018). Critical analysis of e-health readiness as-
sessment frameworks: suitability for application in developing countries. Journal of tele-
medicine and telecare, 24(2): 110-117 https://doi.org/10.1177/1357633x16686548
iJOE ‒ Vol. 15, No. 8, 2019
105
Paper—Current State of ICT in Healthcare Delivery in Developing Countries
[42] Le Pape, M. A., Suárez, J. C. N., Mhayi, A., Haazen, D., &Özaltin, E. (2017). Developing
an HMIS Architecture Framework to Support a National Health Care eHealth Strategy Re-
form: A Case Study from Morocco. Health Systems & Reform, 3(1): 56-67 https://doi.org/
10.1080/23288604.2017.1265041
[43] Kiberu, V. M., Mars, M., & Scott, R. E. (2017). Barriers and opportunities to implementa-
tion of sustainable e-Health programmes in Uganda: A literature review. African journal of
primary health care & family medicine, 9(1): 1-10 https://doi.org/10.4102/phcfm.v9i1.
1277
[44] Harding, K., Biks, G. A., Adefris, M., Loehr, J., Gashaye, K. T., Tilahun, B., ...&Mersha,
T. B. (2018). A mobile health model supporting Ethiopia's eHealth strategy. Digital Medi-
cine, 4(2): 54 https://doi.org/10.4103/digm.digm_10_18
[45] Muinga, N., Magare, S., Monda, J., Kamau, O., Houston, S., Fraser, H., Powell, J., Eng-
lish, M., Paton, C. (2018). Implementing an open source electronic health record system in
Kenyan health care facilities: Case study. JMIR medical informatics, 6(2). https://doi.org/
10.2196/preprints.8403
[46] Dobrev, A., Stroetmann, V., Stroetmann, K., Artmann, J., Kersting, A., Kasiri, N., Ze-
gners, D., &Lilischkis, S., (2008) Sources of financing and policy recommendations to
Member States and the European Commission on boosting eHealth investment. Final re-
port of the Financing eHealth study. Available at:
http://www.financingehealth.eu/downloads/documents/FeH_D5_3_final_study_report.pdf
https://doi.org/10.4414/smi.26.00212
[47] Basher, M.A. & Roy, P.C. (2011). Introducing an e-Health card for Developing Coun-
tries: A case study of Bangladesh. Master Thesis, Stockholm University, Sweden., p.
38
[48] Ouma, S., &Herselman, M. E. (2008). E-health in rural areas: case of developing coun-
tries. International Journal of Biological and Life Sciences, 4(4): 194-200
[49] Abodunrin, O., & Akande, T. (2009). Knowledge and perception of e-health and telemedi-
cine among health professionals in LAUTECH teaching hospital, Osogbo, Nigeria. Inter-
national Journal of Health Research, 2(1): 51-58 https://doi.org/10.4314/ijhr.v2i1.55388
[50] Kulyk, O. (2014). How to evaluate the success of technology-based interventions. Availa-
ble at: https://www.utwente.nl/en/bms/ehealth/documents/workshop-2014/workshop-
ehealth-icbm2014-evaluation-methods-o.kulyk.pdf
[51] Bergmo, T. S. (2015). How to measure costs and benefits of eHealth interventions: an
overview of methods and frameworks. Journal of medical Internet research, 17(11). https://
doi.org/10.2196/jmir.4521
[52] Gregory, M., &Tembo, S. (2017). Implementation of E-health in Developing Countries
Challenges and Opportunities: A Case of Zambia. Science and Technology, 7(2): 41-53
6 Authors
Adebayo Omotosho is currently a visiting research in Internet Technologies and
System Group at Hasso Plattner Institute, University of Potsdam, Germany. He is
alsoa lecturerin the Department of Computer Science, Landmark University, Omu-
Aran. He received his Ph.D. in Computer Science at Ladoke Akintola University of
Technology in 2016. He is a Seasoned Computer Programmer and has taken part in a
number of programming competitions in C/C++/C#. He is a member of the Nigeria
Computer Society (NCS), Computer Professional [Registration Council] of Nigeria
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Paper—Current State of ICT in Healthcare Delivery in Developing Countries
(CPN), Computer Science Teachers Association for Computing Machinery (ACM),
and International Association of Computer Science and Information Technology. His
research interests are health informatics, computer security, machine learning, and
biometrics.
Peace Ayegba is a research assistant in the Department of Computer Science,
Landmark University Omu-Aran. She is currently on her M Sc degree and her re-
search areas are computer security, human-computer interaction and artificial intelli-
gence.
Justice Emuoyibofarhe is a Professor of Computing at the Ladoke Akintola Uni-
versity of Technology. He received his Ph.D. in 2004. He specializes in neuro-fuzzy
computing computational optimization. He had post-doctoral fellowship at the Centre
of Excellence for Mobile e-service, University of Zululand, South Africa in 2006. He
is a member of the IEEE Computational Intelligence Society. He is also a Visiting
Researcher at the Hasso Plattner Institute, University of Potsdam, Germany. His pre-
sent research area is in the application of mobile computing and wireless communica-
tion to e-health and telemedicine.
Christoph Meinel is a German Scientist and a University Professor of Computer
Sciences. He is President and CEO of the Hasso Plattner Institute (HPI) for IT Sys-
tems Engineering at the University of Potsdam (Germany), and a Professor for Inter-
net Technologies and Systems. Besides his teaching activities in Potsdam, he is an
Honorary Professor at the Technical University of Beijing (China), a Visiting Profes-
sor at the Shanghai University (China), and a Senior Research Fellow of SnT at the
University of Luxembourg. He is a Chairman or a member of various international
scientific boards and program committees and has organized several internal sympo-
sia and conferences
Article submitted 2019-02-09. Resubmitted 2019-03-27. Final acceptance 2019-03-28. Final version
published as submitted by the authors.
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