Ehealth in Zambia and Uganda: HIV/AIDS prevention

“Technology is a major driving force of our civilization. Whether through medicines to heal the sick or products for growing food to feed the hungry, or most recently information and communication technology most accessible to the poor and disenfranchised is the mobile phone. ”- Desmond Tutu

Introductory Remarks
During the 1990s the Internet exploded across computers and a number of e-terms began to surface and proliferate. Email brought new possibilities for people as communication was rejuvenated and rapidly enhanced how individuals share experiences. E-commerce proposed new ways of conducting business and financial transaction through the Internet. The introduction of electronic health (ehealth) presented the promise of new information and communication technologies to improve health and the health care system (Oh, Rizo, Enkin, & Jadad, 2005). Health communications are rapidly changing due to information and communication technologies (ICT).  Around the world ICTs are an important part in the ways health professionals, researchers and patients work and deal with one another. In industrialized countries such as United Kingdom, US, Canada, and Japan to name a few, patients seek medical advice online before meeting with their physicians in order to ask appropriate questions; this has also become an essential tool for medical professionals to stay updated on information and developments within the medical field. The Internet and ICTs have allowed health professions from different regions of the world the ability to network as well as collaboration on health research (Ojo, 2006).

Health systems around the world are faced with significant challenges in financing and providing quality care at an affordable rate. Health systems within developing countries such as Uganda and Zambia are faced with numerous other challenges such as shortages of trained health care professionals, increasing burdens of disease, poor infrastructure and unequal access to healthcare and education (The Rockefeller Foundation, 2008). One of the major challenges developing countries are faced with is a high prevalence of HIV/AIDS. Although African countries only have 11% of the global population, 60% of the HIV/AIDS cases reside within the continent. Africa is often symbolized as a continent of poverty and faces challenges to educate and provide medical care to both the rich and the poor (Samake & Mbarika, 2005). Reducing the prevalence of HIV/AIDS is one of the Millennium Development Goals (MDGs) and sees health as a key component to development. When health issues are tackled and resolved other areas of development like economy benefits from improved social capital. Thus ehealth is one of many innovative tools that can be used to address HIV/AIDS prevention programs, in collaboration with UN MDGs. 

Thesis
The purpose of this paper is to argue that although national ehealth policy is acknowledged as a step in the right direction,  it does not however lead to successful ehealth HIV prevention programs. In order to improve the quality of life, and decrease HIV prevalence rates in Uganda and Zambia the government must work with local, national and international NGOS, bilateral and multilateral organizations, and integrate beneficiaries through an inclusive process  of implementing preventive health.

Throughout this paper the role that ehealth has, and continues to have, in HIV/AIDS prevention in Uganda and Zambia will be explored. Uganda’s ehealth national strategy is part of the national ICT policy, while Zambia currently has no national ehealth policy in place. Throughout this research project key stakeholders such as national governments, local NGOs, international NGOs, multilateral and bilateral organizations in both Uganda and Zambia will be acknowledged and evaluated to determine what role they play within ehealth initiatives and whether a national ehealth policy is necessary. Beneficiaries will be identified, as wall as the impacts ehealth has had on populations in Uganda and Zambia. Finally, current and past projects will be examined, evaluated and analyzed to determine both costs and benefits of ehealth prevention in the global south.

Personal Interest, Assumptions and Personal Bias
Zambia and Uganda were chosen as the central focus of this paper as I had the opportunity to spend a few months working in small villages outside Livingstone, Zambia before I began my undergraduate degree. After experiencing rural clinics first hand I had an inside look at the HIV/AIDS crisis as well as the lack of infrastructure within the health system. After preliminary research I observed Zambia had no national ehealth policy, yet recognized HIV/AIDS as a priority issue in need of support and would be a good candidate for learning from a country, which has excelled in the ehealth sector. With Uganda establishing a national ehealth policy in 2006 I was expecting a vast collection of publications and to establish and compare ehealth projects within the vicinity of preventive ehealth given that Uganda would be a great leader. Uganda I chose on the presumption that because they had an early start in comparison to other developing nations on initiating a ehealth policy along with the significant decrease in HIV prevalence rates that Uganda would be a great example of a country to learn from.  However I have encouraged a few challenges such as a lack of literature as I continue to research ehealth in Uganda and Zambia.  Literature on Zambia including the involvement at the government level is scarce while the results of projects that have been implemented is also limited due to ehealth being a relatively new field. Although there is more academic research and literature on projects and results from Uganda, projects are on a small scale without the support of the national government thus finding it difficult to determine what exactly the Government of Uganda’s ehealth is supporting. Although I have experienced ongoing challenges, these are also findings in that assumptions I had made about ehealth within Uganda and Zambia needs to be revisited.

One of the many AIDS prevention programs run by locals in a rural community outside Livingstone.

Living in Zambia for a few months may bias my own investigation of the country. I saw Zambia in a certain light in terms of the positive actions towards HIV/AIDS prevention programs that were in place during my visit, however this view of Livingstone and surrounding rural areas may bias my view for the rest of the country as Livingstone typically was better off due to constant flow of tourist volunteers.  Also I was in Zambia in 2007, five years ago and political, economic and social situations may not be identical and thus my perception of Zambia in 2007 could bias my view in Zambia today. Finally, being a middle class Canadian may also bias my research as I have access to the internet and mobile devices at my convenience and view these technological devices as necessary for my daily routine, however in rural Uganda and Zambia where a resident may not have ever experienced what the internet or mobile phones have to offer may not view these technologies the same way, therefore could also bias my research.

What is ehealth?
Across published academic journals there are an abundance of unique definitions of what ehealth is; however the common factor between all the definitions is that they involve technology and health. Ehealth is defined by World Health Organization (WHO, 2012) as, “the transfer of health resources and health care by electronic means. E-health provides a new method for using health resources – such as information, money, and medicines – and in time should help to improve efficient use of these resources”. Eysenbach (2001) adds that ehealth is the intersection of medical informatics, public health and business and is a commitment for networked, global thinking to improve health care locally, regionally and worldwide using information and communication technology. Ehealth is about rethinking the ways in which information is collected, exchanged and transformed in order to improve health outcomes (Ibrahim, 2009). Potential benefits include the possibility for ehealth to be a powerful, low-cost method to deliver health intervention and prevention programs to large numbers of young people across diverse geographic regions. In resource-limited settings ehealth is a potential solution to boost efficiency, equity, and quality where cost effectiveness interventions are most needed from ehealth initiatives(Ybarra, Kiwanuka, Emenyonu, & Bangsberg, 2006). Ehealth is comprised of technologies such as Internet, text messages and internet from mobile devices, video conferencing, satellite, wired data networks to name a few.

Although there are various ehealth technologies, the Internet and mhealth are two pathways providing vast possibilities within the health sector in Africa. Mhealth (mobile health) is defined by WHO (2011) as an area of ehealth and it is the provision of health services and information via mobile technologies such as mobile phones and Personal Digital Assistants (PDAs). Mobile technologies have been expanding at rapid rates. In Africa alone mobile phones grew in popularity from 49 million in 2002 to 280 million in 2007, with an expected increase to 600 million subscriptions during 2012. Mhealth applications have explored the possibility of addressing health challenges using mobile phones and other mobile devices in Africa and other regions of the developing world (Danis, et al., 2010). Although Internet has increased in popularity in recent years, in 2011, 26% of the people in developing countries had access, while 79% had a mobile phone subscription (Thirumurthy & Lester, 2012). Mobile phones offer innovative and cost-effective implementation of mhealth interventions (Chang, et al., 2011). However, literature and evidence however remains limited on the effectiveness of mhealth initiates and throughout this research paper project preventive HIV/AIDS mhealth projects in Uganda and Zambia will be evaluated for their impact on the population in terms of standard of living and effectiveness.

Continued challenges of implementing ehealth within developing nations include, low school enrollment, high illiteracy rates, low per capital incomes, widespread poverty, and weak ICT connectivity that challenges the sustainability of ehealth initiatives. ICT connectivity varies among countries but also within nations among income levels and geographical locations (Kirigia, Seddoh, Gatwiri, Muthuri, & Seddoh, 2005). Poor policy and regulatory environment also pose challenges to developing nations implementing ehealth initiatives (Souter, 2010).

Uganda and Zambia are no exception to the challenges that ICT and ehealth pose for implementing preventive initiatives. However both countries could potentially improve health outcomes and prevent new cases of HIV/AIDS through preventive projects. Major actors within the ICT and ehealth sector will be used to investigate ehealth initiatives in Uganda and Zambia such actors include United Nations and other international bodies such as the WHO, International Telecommunication Union, UN Global Alliance for ICT and Development, Non-governmental organizations (NGOs) such as the Rockefeller Foundation, as well as the national Governments of Uganda and Zambia. 

Uganda & Zambia: Background information

Uganda, a landlocked country in East Africa, boarded by Kenya, South Sudan, Democratic Republic of Congo and Tanzania has a current population of 32.7 million, 50% of which are between the ages of 15-64 (Nchise, Boateng, Shu, & Mbarika, 2012). Among 15-49 year olds the prevalence rates is an estimated 6.4%. 10-24 years of age comprise of 33% of the total Ugandan population, yet comprise of 50% of the countries HIV/AIDS cases. The main mode of HIV transmission is via heterosexual intercourse. 64% of Ugandan teens have has sexual intercourse by the age of 18 (rate are similar to US where by 19, 70% of teens have engaged in intercourse) (Ybarra, Kiwanuka, Emenyonu, & Bangsberg, 2006). The Ministry of Health recognizes that HIV has stabilized however continues to put a strain on resources and economic development, as economic development is dependent on social and human development. Within Uganda’s health policy priority health care intervention and services are mentioned and aim to address the high disease burdens including HIV/AIDS and health initiatives are intended to reach all citizens of Uganda with emphasis on vulnerable populations. HIV prevention strategies are recognized within this health policy with an emphasis on implementation of new evidence based HIV prevention strategies, increasing access to ART and strengthening monitoring and evaluation of HIV/AIDS programmes (Government of Uganda Ministry of Health, 2009)

Uganda is currently implementing a number of ICT-related initiatives in the area of eGovernment, Technology-enhanced learning, e-commerce ICT for rural development as well as ehealth. The objective of ehealth is to improve health care delivery through continuing medical education for rural health workers, which includes the use of multimedia for rural health workers(Loi Mirembe, 2010).

Secondly, The Republic of Zambia once known as Northern Rhodesia is a landlocked country in Southern Africa with a current population according to the World Bank (2011) of 13. 4 million. Like most developing countries Zambia is comprised of an urban and rural demographic structure. The urban areas are economically better off with access to basic infrastructure such as treated water, electricity and telephones urban areas lack qualified health professionals while rural areas struggle to provide basic infrastructure to provide basic services. The health sector in Zambia requires primary health care facilities and trained medical staff. Zambia currently has 1200 doctors whom mostly reside in urban areas for 13 million individuals while the urban areas have a difficult time attracting medical professionals due to the distance from centrally located infrastructure in urban areas. Zambia like Uganda struggles with high prevalence rate of HIV/AIDS among 15-49 year olds. The prevalence rate in Zambia dropped from 16.1% in 2002 to 14.3 in 2007. 

Although Zambia currently does not have a national ehealth policy, Zambia does have an ICT policy, which was first, introduced as one of thirteen integrated components of the Fifth National Development Plan 2006-2010. Within this development plan issued as a Government-led initiative with the intention of involving the private sector through Public-Private Partnerships recognizes technology as priority section in order to attain Millennium Development Goals. Within the ICT component health is recognized as an important avenue in which ICT can potentially contribute to increasing efficiency and performance of the health sector within remote diagnosis and treatment (Ministry of Communication and Transport, 2006). The continuous exchange of skills and knowledge is recognized as a critical component within the ICT section of Zambia’s developmental plan in which Telemedicine can be used within medical institutions to maximize services available in rural areas as well as provide a foundation for informed division making with the health sector (Ministry of Communication and Transport, 2006). Like Uganda Zambia has a high mobile phone rate of 34.07 per 100 people and currently has on going projects, which use mobile devices (World Health Organization, 2011).

Zambia faces challenges within implementing ICT within the health sector due to low ICT literacy within the country, high cost of technology to Zambians, brain drain challenges as well as a lack of needed infrastructure to sustain ehealth initiates (Nyirenda & Cropf, 2010).

Throughout this research project both Uganda and Zambia will be analyzed for their progress, and success of preventive ehealth programs while determining what role the national Government of each country should have in order to ensure sustainable programs increasing the quality of life for residents in Uganda and Zambia.  With 5 billion mobile phone subscriptions in the world, with over 85% of the world covered by a commercial wireless signal ehealth in areas such as Uganda and Zambia means there is room for technological innovation and hope decreases in new cases of HIV (World Health Organization, 2011).

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