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Electronic health is one of the most popular applications of information 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 carries the highest percentage of the world's global diseases despite its certain level 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 proposes a framework for further improvement.
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PaperCurrent 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
AbstractElectronic 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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PaperCurrent State of ICT in Healthcare Delivery in Developing Countries
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
[27]
South Africa
Telemedicine
Video conferencing for e-
health
[40]
Ghana, Rwanda, Kenya,
South Africa, Ghana,
Lesotho, Zimbabwe,
Uganda, Tanzania,
Mozambique
Electronic medical
record (EMR)
OpenMRS
[21]
Brazil
EHR
Unspecified
[41]
Botswana
mHealth
Not specified
[22]
Tanzania, Ghana
Electronic clinical
decision support
system
eCDSS
[42]
Morocco, Tunisia
Health Management
Information System
(HMIS),
Electronic Medical
Record,
Hospital Infor-
mation System,
Teleservices
Unspecified
[25, 30]
Ghana
mHealth, Telemedi-
cine
Mobile interactive voice
response system (IVR)
[43]
Uganda
mHealth, Electronic
Medical Record
Matibabu application, mTrack,
District health management
system (DHIS2)
[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
[20, 44]
Ethiopia
Telemedicine,
mHealth
Telemed-ETH, Project Orchid
mHealth platform
[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
[37]
South Africa, Zambia,
Uganda,
Jamaica
EMR, Electronic
Health Record
Bahmni, GnuHealth
[36]
Bangladesh
Telehealth
Portable Health Clinic (PHC)
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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PaperCurrent State of ICT in Healthcare Delivery in Developing Countries
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.
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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
106
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PaperCurrent 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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... The problem of shortages in trained global healthcare force and support, provision of geriatric and mental health services, infrastructure for timely healthcare services have affected rural healthcare services more than urban services [5]. The lack of healthcare insurance and the treatment costs incurred compounded with the insufficient healthcare expenditure of Gross National Product (G.N.P.) on health has worsened this situation [34]. The rural population of elderly, sick, uninsured and suffering from chronic diseases is significantly higher than its urban counterpart, which need to be addressed [33]. ...
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... Although the World Health Organization claims that more than half of their member states have an eHealth strategy, actual implementation of their strategies is not always followed. This is clear from published studies and concerns expressed by many researchers [3][4][5][6][7]. For example, Kiberu et al [4] suggest that although many sub-Saharan African countries are evaluating eHealth as a means of improving health care accessibility, several are engaged in the proof-of-concept stage of unsustainable pilot projects. ...
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... Omotosho et al. [30]; carried out a research to ascertain the growth rate of ICT users with e-health strategies of wireless technology. From findings advised users to invest on ICT for Internet of Things(IoT) without considering its health related challenges where machines can communicate and expose human to radiations. ...
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This paper explores the known but silent effects of ICT devices on our environment and health. The use of ICT devices is very crucial and paramount to our daily activities but the negative and positive effects especially with the new idea of Internet Of things (IOT) that will make the sensors part of our daily routine till we go to bed. The negative effect ranges from exposure to toxic compounds, high energy consumption due to high reliance on ICT devices, exposures us to non-thermal radio frequency radiation from Wifi, cellular and many more. The positive effect of ICT and its associated devices are too numerous to list which have been adopted in every spheres of human endeavour. The aim is to build a K-nearest neighbor and random forest technique to access the impact of ICT devices in detecting human heart diseases caused by ICT radiations. This will help reduce the stress of searching and waiting with hope for specialists to look at results of images when diagnosis are performed by lab scientists in determining whether the patient is fine or have heart disease. This contributes positively to the healthcare delivery system and promotes our next level of digital economy in the society at large because of the limited number of medical doctors. We adopted the k-fold cross validation test to have a better classification report. The KNN produced 90% cross validation test accuracy which was observed to be higher than the random forest with 85.71% cross validated accuracy.
... Omotosho et al. [30]; carried out a research to ascertain the growth rate of ICT users with e-health strategies of wireless technology. From findings advised users to invest on ICT for Internet of Things(IoT) without considering its health related challenges where machines can communicate and expose human to radiations. ...
Research Proposal
Full-text available
This paper explores the known but silent effects of ICT devices on our environment and health. The use of ICT devices is very crucial and paramount to our daily activities but the negative and positive effects especially with the new idea of Internet Of things (IOT) that will make the sensors part of our daily routine till we go to bed. The negative effect ranges from exposure to toxic compounds, high energy consumption due to high reliance on ICT devices, exposures us to non-thermal radio frequency radiation from Wifi, cellular and many more. The positive effect of ICT and its associated devices are too numerous to list which have been adopted in every spheres of human endeavour. The aim is to build a K-nearest neighbor and random forest technique to access the impact of ICT devices in detecting human heart diseases caused by ICT radiations. This will help reduce the stress of searching and waiting with hope for specialists to look at results of images when diagnosis are performed by lab scientists in determining whether the patient is fine or have heart disease. This contributes positively to the healthcare delivery system and promotes our next level of digital economy in the society at large because of the limited number of medical doctors. We adopted the k-fold cross validation test to have a better classification report. The KNN produced 90% cross validation test accuracy which was observed to be higher than the random forest with 85.71% cross validated accuracy.
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... Interactive eHealth and m-Health services online allow individuals to consult their medical records themselves [20] using the web or mobile interfaces on a computer or smartphone. E-Health is one of the most famous digital tools of information and communication technologies and it has served vastly to public health delivery through the provision of quality health service [21], it is also facilitating immediate communication and information sharing between different health actors through dynamic social interactions via information systems [22] or the telemedicine healthcare system [23]. Such systems are set up on the internet and serve primarily to support the patient and meet his biopsychosocial needs. ...
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This study aimed to evaluate the prevalence of burnout among nurses, to determine the socio-demographic characteristics associated with burnout, and to assess the influence of the practice of physical activities on burnout. This is an observational study of a cross-sectional type. A self-administered survey was used to determine the professional and socio-demographic characteristics. The Ricci-Gagnon questionnaire to assess the level of physical activity and sports practice and the Copenhagen Burnout Inventory to evaluate burnout. In total, 16.7% of the participating nurses displayed a high level of general burnout (63.3% medium, 20% low), and 23% displayed a high level of patient-related burnout (34% medium, 43% low). Physical activity had no protective effect against burnout, as 87% of participants were physically active. This research result confirmed what exists in other scientific publications; the prevalence of burnout is a reality in the health professions. It is necessary to think of setting up accompaniments to sensitize nurses for primary prevention against burnout.
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E-Health is being implemented in many developing countries to support healthcare services and the Zambia National Health Strategic Plan seeks to provide the strategic framework for ensuring an efficient, coordinated and well managed health sector by adopting these applications. Despite the national e-Health systems implementation programme covering over 666 out of 1956 representing 34% of health facilities with e-Health applications where 37 are functional model sites representing 1.8%, this adoption rate remains relatively low to achieve meaningful use and can be attributed to many factors. This study was designed to achieve a well-balanced view and experiences among Health Care Providers on e-Health implementation. A health facility institution based mixed methodology was conducted on study participants that were provided with pretested self-administered questionnaires to collect the required data for case analysis. The main content of this paper demonstrates currently e-Health implementation is characterized by high levels of training gaps, lack of a regulatory policy, technology use challenges and many other factors. The output of this research is an integrated e-Health with a new paradigm to information sharing. Although many opportunities exist and are not limited to, but inclusive of stakeholder support, functional e-Health model sites, availability of e-Health training laboratories and government initiatives to implement E-government the challenges still remain unresolved. The study recommends pre and in-service examinable e-Health training curriculum, implementation of a mandatory use e-Health Policy and confront data sharing challenges amongst health care institutions to further encourage adoption of e-Health.
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Electronic prescribing or Electronic prescription (EP) is the computer-based electronic generation and transmission of a prescription. EP systems help to increase accuracy and safety of patient prescription and reduce costs through improved legibility and electronic delivery. The motivation for EP is greater safety of drug use and to counter the current unacceptable levels of adverse drug events. This study evaluated the feasibility of hospitals in Nigeria to adopt an EP system. A survey was conducted in four hospitals in Nigeria to determine the economic, technical and organisational feasibility of adopting e-prescribing. Respondents included 42 medical practitioners-doctors, pharmacists, pharmacy technicians and assistants-working at the hospitals at the time of the survey. Respondents felt that implementation of an EP system is economically feasible (p=0.031) and organisationally feasible (p=0.032) but were ambivalent as to whether it is technically feasible (p=0.446). However, inadequate funding by the government does not provide for the health sector to acquire the necessary resources and training skills.
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Objectives: In this study, we developed a neuro-fuzzy based system for classification of cancerous and non-cancerous lung cells. Methods: Images were pre-processed using median filter algorithm, segmented using marker-controlled watershed algorithm, and were extracted using gray-level co-occurrence matrix. A hybridized diagnosis system that made use of neural network and fuzzy logic for classification of lung cells into cancerous and non-cancerous cells is modelled. Computed tomography (CT) scan image dataset of the lung was downloaded from The Cancer Imaging Archive dataset. Neural network performed the training and classification of the lung cells with back-propagation algorithm, while the cancerous cells were passed into fuzzy inference system to determine the lung cancer stage. Results: Our system was able to successfully classify the imported CT scan images into normal or abnormal with considerably high accuracy of 70% and precision of 89%. This system can support physicians in decision making when diagnosing cancer.
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INTRODUCTION eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about effectiveness of eHealth tools for improving quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project (‘EXTEND’) that aims to evaluate the impact of eHealth tools on health system functions and health outcomes. METHODOLOGY AND ANALYSIS This multi-site, mixed-methods evaluation includes a non-randomised, cluster trial design. The study comprises three phases—baseline, mid-line and end-line evaluations—that involve: i) process evaluation of video training and digitization of health data interventions; ii) evaluation of contextual influences on the implementation of interventions; and iii) impact evaluation of results of the project. A convergent mixed-methods model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the University of Leeds and three States’ Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health; at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN32105372 KEY WORDS: eHealth, Nigeria, rural populations, satellite communication, mixed-methods evaluation, non-randomised cluster trial
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Background: Patients preferences have recently been identified as important factors in clinical practice. However, there is little information on how patient eHealth preferences influence healthcare professionals’ (HCPs) choices to use technology in their clinical practice especially in Sub-Saharan Africa (SSA). Aim: This is part of a study which explored factors influencing eHealth adoption and use among healthcare professionals in SSA. This section of the study aimed to uncover how patient preferences influence HCPs decisions on eHealth for clinical practice. Method: A mixed-method approach was adopted using Q-methodology. The viewpoints of thirty-six HCPs were explored in relation to eHealth adoption in their clinical practice. Each participant rank-ordered forty-six statements in relation to how they agreed or disagreed with them in their own clinical practice. This was followed by an interview to explore the reasons for their individual rankings. Results: Four viewpoints emerged showing how HCPs consider patient preferences when making decisions to use eHealth in their clinical practice. Conclusion: Findings suggest divergent viewpoints in relation to the role patient preferences play HCPs eHealth adoption in their clinical practices. These viewpoints could be seen as a tripartite relationship identifying how important patient eHealth preference influence HCP clinical choices. Keywords: eHealth, Healthcare professionals, Q-methodology, patient preferences, mixed-method approach, sub-Saharan Africa.
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Background: Improving access to health care services in both developed and developing countries through information communication technology (ICT) has been getting particular attention from government, medical researchers and practitioners. This has seen many governments proposing the implementation of healthcare systems that are centred on technology, while researchers and practitioners have been arguing for policies that promote the use of technology in healthcare provision. Objective: The main objective of this study was to determine the factors influencing implementation of e-health by medical doctors in public hospitals in Zimbabwe. Methods: The study was guided by a qualitative research in conjunction with multiple-case studies. Qualitative data were collected using 20 semi-structured interviews from selected hospitals concerning the implementation of e-health by medical doctors in public hospitals. Hospitals were selected using random sampling, while purposive sampling was used to select the 20 doctors. In addition, the researcher conducted direct observations at five hospitals. Furthermore, data concerning policy issues in Zimbabwe’s e-health were collected using document review process. Data from the interviews were analysed using data-driven thematic coding. This solo approach was conducted because the researcher intended to reveal e-health influencing factors that could not be revealed by related literature. Results: This study reveals that the implementation of e-health by medical doctors in public hospitals in Zimbabwe is influenced by both internal and external factors. Internal factors include ICT infrastructure and e-health technologies, ICT skills and knowledge, technical support, security concerns, lack of basic medical facilities, demographic factors such as age and doctor–patient relationship. External factors are health policy, funding and bureaucracy. Conclusion: The idea of e-health is relatively new to healthcare centres in Zimbabwe. Its application has not been sufficiently addressed. The study shows that the success of an e-health system depends on internal and external factors. There is a great potential for implementing e-health in Zimbabwe if these factors are taken into consideration. Otherwise, Zimbabwe will continue to lag behind in the implementation of e-health systems in public hospitals.
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Background: The electronic prescription system has emerged to reduce the ambiguity and misunderstanding associated with handwritten prescriptions. The opportunities and challenges of e-prescription system, its impact on reducing medication error, and improving patient's safety have been widely studied. However, not enough studies were conducted to explore and quantify the factors that affect rural patients' compliance with e-prescription, especially from the perspective of Asian developing countries where most of the world's population resides. Objective: The objective of this study is to explore and assess the factors that affect rural patients' primary compliance with e-prescription in Bangladesh. Methods: Data were collected from 95 randomly selected rural patients who received e-prescription through a field survey with a structured questionnaire from Bheramara subdistrict, Bangladesh, during June and July 2016. Logistic regression analysis was performed to test the research hypotheses. Results: The study found patients' gender as the most significantly influential factor (regression coefficient [Coef.] = 2.02, odds ratio [OR] = 7.51, p < 0.05) followed by visiting frequency (Coef. = 0.99, OR = 2.70, p < 0.05); education (Coef. = 0.92, OR = 2.51, p < 0.05); and distance to healthcare facility (Coef. = 0.82, OR = 2.26, p < 0.01). However, patients' age, monthly family expenditure, and use of cell phone were found insignificant. The model explains 59.40% deviance (R2 = 0.5940) in the response variable with its constructs. And the "Hosmer-Lemeshow" goodness-of-fit score (0.99) is also above the standard threshold (0.05), which indicates the data fit well with the model. Conclusions: The findings of this study are expected to be helpful for e-health service providers to gain a better understanding of the factors that influence their patients to comply with e-prescriptions.
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There has been a growing interest in Health Informatics applications, research, and education within the Middle East and North African Region over the past twenty years. People of this region share similar cultural and religious values, primarily speak the Arabic language, and have similar health care related issues, which are in dire need of being addressed. Health Informatics efforts, organizations, and initiatives within the region have been largely under-represented within, but not ignored by, the International Medical Informatics Association (IMIA). Attempts to create bonds and collaboration between the different organizations of the region have remained scattered, and often, resulted in failure despite the fact that the need for a united health informatics collaborative within the region has never been more crucial than today. During the 2017 MEDINFO, held in Hangzhou, China, a new organization, the Middle East and North African Health Informatics Association (MENAHIA) was conceived as a regional non-governmental organization to promote and facilitate health informatics uptake within the region endorsing health informatics research and educational initiatives of the 22 countries represented within the region. This paper provides an overview of the collaboration and efforts to date in forming MENAHIA and displays the variety of initiatives that are already occurring within the MENAHIA region, which MENAHIA will help, endorse, support, share, and improve within the international forum of health informatics.