ICT and health systems: unlocking African healthcare

Could technology be the key to overcoming Africas health problems?

Who will be the winners in the mobile payments battle?

ICT and health systems in Africa

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Could technology be the key to overcoming Africas health problems?

Use of Information and Communications Technology (ICT) is expanding rapidly across the healthcare sector
Technology cannot solve all problems by itself, but it can assist health service delivery by reducing travel overheads and enabling faster communications. Over 2% of healthcare spending in Africa is ICTrelated, with a strong annual growth of 9%. While many projects are still at an experimental stage, they offer an indication of how this domain will evolve. Health-related challenges are greater in Africa than anywhere else in the world. Three structural issues affect healthcare across the continent: Health insurance acceptance and use needs to be broadened. This includes protection against non-payment risks. By keeping the moment of payment separate from treatment, insurance encourages use of health services. Software solutions can underpin the risk-sharing process, enable more effective and secure management and encourage financial pooling of risk. There exists a chronic shortage of trained healthcare personnel. Via telemedicine-based solutions, ICT can partially compensate for this shortfall. The quality and reach of healthcare infrastructure can be significantly improved, from treatment centres to medicine distribution,

catalysed by the fight against counterfeit drugs or enabling networks of expertise. ICT can respond here as well, through connecting hospitals, improving operational logistics for medicines and so on. ICT companies cannot solve all of Africas healthcare problems, but they can offer innovative solutions. As shown by the mobile phone payment model (M-Payment) which substitutes for bank accounts and associated mechanisms, ICT services offer alternative solutions to mitigate healthspecific obstacles and those felt more broadly across the continent (such as road quality). While ICT offers one element of the overall response, it still deserves specific focus due to its innovative nature. The challenge for ICT companies (telecommunications operators, equipment providers, software and general IT providers, etc.) is as much to identify economic models that ensure project viability, as to propose appropriate technological solutions to reduce the impact of these structural issues. But how can ICT companies working in this area identify sustainable sources of finance? We estimate that the ICT market for African healthcare is just over a billion dollars, of which half is in five countries South Africa, Nigeria, Egypt, Algeria and Morocco. When considered against the extent of need, this highlights the necessity for financial diversification and reinforcement, whether from private or public sources, at a local or international level.

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ICT and health systems in Africa

Diagnosing Africas health

Sub-Saharan Africa is plagued by many diseases and lacks various resources in each country. Traditional tropical diseases (Such as malaria, trypanosomiasis the infamous sleeping sickness, Ebola, etc.) and illnesses relating to modern life (changing health situation in cities, AIDS epidemic) affect large sections of the continent while the lack of resources to cure them is acutely felt.

For comparison, the average figure in France is greater than 3,000 euros. According to a 2007 study from the International Finance Corporation (IFC)4, about 60% of the 17 billion dollars total health expenditure across sub-Saharan Africa comes from private sources (commercial organisations, social enterprises, NGOs, etc.) and about 50% goes to private companies. Meanwhile, the informal health sector encompassing healers, midwives and medicine sellers cannot be ignored. In Zambia, 40,000 practising traditional healers receive 60% of total health payments from households (13% of total health spending) and in rural Nigeria, initial consultations take place with a traditional healer in 12% of cases.

Developing the market for health and related ICT services in Africa1
Despite the challenges listed above and contrary to popular belief, financial resources do exist. In fact, health spending in African countries is linked to country wealth whatever the standard of living, constituting about 4% of GNP, as shown by empirical studies from the World Health Organisation (WHO)2 . Overall health spending across the continent rose to 51 billion dollars in 20103, i.e. slightly more than 50 dollars per person.

Health issues in Africa

Beyond these statistics, three significant issues stand out regarding the development of a stronger African health sector. They concern the three major

Source: La Documentation Francaise, UNDP, 2005, WHO, 2003

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In Zambia, 40,000 practising traditional healers receive 60% of total health payments from households
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health-related shortages across the continent: financial structures, competent personnel and sufficiently developed infrastructure. These elements are crucial to understanding healthcarerelated issues in Africa7. Promoting health insurance African health services financing would greatly benefit from a system of health insurance8 in each country. Health insurance protects against financial risk; in addition, the moment of payment is kept separate from treatment, encouraging patients to

use medical services. Insurance requires a similar eco-system to the one enabling access to healthcare in Europe. Health insurance provides an opportunity for both healthcare providers and beneficiaries, as risk-sharing approaches are widely seen as better than one-off payment methods9. They provide the general population with protection against financial risk and encourage a level of fairness via shared financing. Risk-sharing approaches (e.g. where risk is shouldered by the business and/ or the government) aid access to healthcare and contribute to better health across the population. However according to a WHO report10, health spending within a social security or a pre-paid private insurance framework makes up less than 15% of total expenditure in nearly all sub-Saharan African countries (e.g. 14.9% in Mali, 6.9% in the Ivory Coast, 3.0% in Madagascar and near-zero in Cameroon).

Figure 1: The informal health sector cannot be ignored Distribution of healthcare spend (USD billions) by provider type (2005)

%, billions of dollars 100% = 16,7 100% = 8,3

Public

~50%

~65%

Commercial

Private

~50%

~15% ~10% ~10%

Social enterprise Not for profit Traditional healers

Breakdown of providers

Private sector providers:

Source: tude IFC, comptes nationaux de la sant, 2005

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ICT and health systems in Africa

Figure 2: African healthcare ICT spend is dominated by only a few countries Healthcare ICT spend (USD Millions) across Africa

Country
South Africa Nigeria Egypt Algeria Morocco Libya Angola Sudan Tunisia Kenya Ethiopia Cameroon Ivory Coast Ghana Tanzania Uganda Botswana Zambia Senegal Gabon Equatorial Guinea DR Congo Namibia Mauritius Mozambique Congo Madagascar

Spend ($m)
218.20 133.42 112.65 110.78 60.52 53.24 47.48 35.28 26.16 22.81 16.97 16.64 15.66 13.95 11.69 10.14 9.41 9.40 8.86 8.31 8.03 7.03 6.75 6.37 6.13 6.02 5.87

Country
Mali Burkina Faso Benin Niger Rwanda Malawi Guinea Swaziland Mauritania Somalia Togo Lesotho Sierra Leone Central African Republic Cape Verde Zimbabwe Eritrea Burundi Seychelles Djibouti Liberia The Gambia Chad Comoros Guinea Bissau Sao Tome

Spend ($m)
5.71 5.44 4.71 3.72 3.09 3.04 2.94 2.31 1.92 1.91 1.81 1.64 1.44 1.24 1.20 1.16 1.12 0.82 0.79 0.69 0.50 0.50 0.39 0.34 0.30 0.16

BearingPoint analysis, 2010, based on data from IMF, World bank, OECD, United Nations Conference on trade and development, EBRD, United Nations, Deutsche Bank, Merill Lynch, JP Morgan, Morgan Stanley, Goldman Sachs, Oxford economics, Feri and Consensus Forecasts, Missions conomiques et ambassades de France, Gouvernements, Banques Centrales et Missions conomiques et ambassades franaises

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11%
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Countries in sub-Saharan Africa represent 11% of the global population but make up 25% of the world death rate

25%

By developing software solutions to underpin the risk-sharing process, ICT companies can contribute to more effective and secure management and encourage the financial pooling of risk. They help improve the current information systems efficiency, and moving forward can enable creation of new software packages11. Compensating shortage of medical personnel Another problem concerns human resources. Countries in sub-Saharan Africa represent 11% of the global population but make up 25% of the world death rate12 against 9% in Europe. In an unfortunate inverse pattern, health-related staff population

Improving quality and density of general infrastructure linked to healthcare

A third issue covers the entire healthcare supply chain and therefore health centres, traceability of medicines (and therefore the fight against drug counterfeiting) and general access to healthcare services. Health infrastructure concerns the entire range of hospital equipment. In many African countries heavy equipment (e.g. scanners) is often concentrated in a very small number of hospitals, or even a single hospital for an entire country. Otherwise, the healthcare network is composed of dispensaries offering first port of call but without adequate equipment to perform analyses or operations15. The sparse distribution of infrastructure combines with frequently large distances between people and resources, exacerbated due to poor-quality road systems only 29% of roads on the African continent are surfaced. As well as direct costs for the individual, attending a hospital just for an examination involves travel costs of up to several days, sometimes for two people. Low-quality or counterfeited medicines are another scourge in the region. Many medicines contain an insufficient quantity of the active ingredient, or indeed do not contain any active ingredient at all. Numerous examples exist: According to the WHO16, in Nigeria, 48% of samples across 27 medicines sold in pharmacies in Lagos and Abuja did not have sufficient quantity of active ingredient and 100% did not contain enough metronidazole17, pyrazinamide18 or anti-malarials. In seven sub-Saharan countries, the majority of medicines sold in the private sector failed to achieve the required level of quality. 47% of chloroquine tablets were not compliant, and 71% of sulfadoxine/pyrimethamine failed dissolution trials.

ICT companies can contribute to more effective and secure management and encourage the financial pooling of risk

percentage in Africa is only 3% compared with 28% on the European continent. Health budgets in Africa are less than 1% of global spending in this domain. Out of 57 countries worldwide that suffer a critical lack of health personnel (such as those defined by the WHO using the Anand Baernighausen regression13), 36 are found in Africa14 with 0.21 doctors per 1000 inhabitants. ICT offers solutions to support automation, telecommunication, collaboration and education, offering a response to the shortfall of medically trained personnel.

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ICT and health systems in Africa

Figure 3: Medical personnel numbers are well below World Health Organisation recommendations Number of healthcare resources per 1000 inhabitants, by region

WHO threshold

Translation? Doctors Nurses and midwives Subtotal: Medical assistants Community health workers Total medical personnel: Managers Researchers Heads of public health General total: 0.21 1.07 1.28 0.03 0.07 1.38 0.04 0.01 0.01 1.44 15% 74% 89% 2% 5% 96% 3% 1% 1% 100%

Sub-Saharan Africa

1.3

South-East Asia

1.7 2.0 2.9 7.0

Eastern Mediterranean

Western Pacific

Americas

Europe

11.1

Source: Joint Learning Initiative, OMS, 2006

These issues illustrate the health challenges in Africa for the coming decades. Information and communications technologies offer several solutions to solve shortages detailed here. ICT companies cannot resolve every problem but they offer one part of an innovation-based starting point for their resolution.

ICTs response to healthcare issues in Africa

ICT companies and healthcare in Africa The healthcare sector has already been positively affected by the use of ICT. Broadly speaking, the key value of technology is to respond to multiple needs in this sector by improving
ICT and health systems in Africa

data exchange and remote communications, enabling productivity gains while gradually improving information exchange. For example, before travelling patients can determine the location/opening hours of a dispensary, or the availability of medicines, or indeed request the direct advice of a doctor19. Healthcare does not stop at diagnosis level; remote communication plays an important role at each link in the healthcare chain from prevention, through treatment to continued improvement (medicines, training etc.). The following table summarises examples of productivity gains linked to ICT in healthcare. Most of the above projects have been in launch mode since 2008 or 2009: initial results confirm their value in each of the challenge areas20.
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Figure 4: ICT provides productivity gains throughout the health chain

Healthcare supply chain 8 Prevention

Information-related needs
D  ata and information exchange (collective access points) I  nformation on risk-based situations (e.g. epidemics) E  ducating on rules of hygiene/safety A  ccess to vaccinations and screening for HIV/AIDS V  erification of medicine authenticity O  btaining a list of compulsory vaccinations I  dentifying patients in need for surveillance of infectious diseases D  ownloading/consulting data libraries C  arrying out remote diagnoses in isolated locations

Principal benefits brought by ICT

U  se of radio or telephony (SMS) to send an alert or a preventative message (these are most broadly spread ICT capabilities in Africa) M  onitoring medicines using technologies such as RFID or other, more secure formats based on NFC

Examples
T  he Psinet programme in Mali, which monitors infant weight P  hones for Health in several African countries: a communication programme (epidemics, good practice) implemented by GSMA

Diagnosis

R  emote management of diagnosis (avoid travel for both patients or doctors) C  ompensates for low numbers of health care staff and also for transport difficulties for patients and doctors L  ogistics monitoring of distribution of medicines O  ptimisation of admittance of patients in hospital (data transfer via fixed line for small hospitals, IP VPN for larger hospitals, and in certain cases GPRS/ EDGE) R  emote transmission of medical information to monitor chronic diseases R  emote coaching of unqualified and basic level personnel A  ny improvement to information systems, either for the patient (e.g. insurance ), or personnel (e.g. e-learning : remote training of health care staff)

H  ealthline from the Grameen Foundation (in Bangladesh, with development planned in Africa) remote diagnosis managed from a hospital and avoiding travel T  ele-radiology in Mali, or Telediagnosis in Egypt, via Orange M  Pedigree, Ghana, fights against counterfeiting of medicines (MTN and Tigo among other partners) e  -logistics for distribution of tritherapies

Treatment

U  ploading or consulting databases R  eceive advice from pharmacists M  onitoring treatment effectiveness exchanges between practitioners V  erification of medicine authenticity R  emote health-related recommendations in isolated locations D  ata capture M  onitoring tele-assistance M  onitoring chronic diseases B  enefit from monitoring vaccinations

Monitoring

A  lert by SMS for taking tritherapy in South Africa (Vodacom)

Improvement

T  raining health personnel T  ransmitting data between peers B  eing informed about health news, new recommendations, alerts, etc. R  eceiving information about medicines (e.g. logistics, changes in dosage, counterfeiting) C  reating a network of rural dispensaries, information centres and the hospital

A  utomation of information flows for employees that benefit from health insurance A  MREF in Kenya (remote training of nurses, prevention, water and hygiene, mobile doctors) R  AFT, French-speaking Africa: expansion of telemedicine, remote education and creation of online medical content

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Promote health insurance via micro-insurance services or automation of information flows A number of early examples of insurance process automation are in progress, improving use of technology in corporate insurance plans. As in France, such schemes only work properly if relevant information systems enable adequate management of patient records, payment/re-imbursement policy rules and control of resulting transactions to be controlled for the benefit of patients, doctors, health professionals and indeed, businesses (through automated restriction of fraud). Senegal, along with the French Institutions for Illness Prevention (Instituts de Prvoyance Maladie, IPM), has been working on such modernisation programmes since 2009, in parallel with developing other channels. As a result, remote medical data

Such services are equally useful for public institutions and their end-users. The difficulty is less about technology and more about identifying a viable economic model, since ICT companies only support the development of an insurance strategy. ITC companies can help develop health insurance or mutual schemes like in Europe but this depends on good will and the capacity of a political entity or an industrial body to support development. In the Maghreb region for example, political power is a good catalyst to drive these developments. In South Africa and Senegal meanwhile, private companies are key stakeholders in the development of mutualised systems22. Prioritising tele-medicine to reduce the shortage of healthcare personnel A number of operators offer tele-medicine solutions which partially compensate for Africas resource shortages and the low distribution of doctors, enabling access to healthcare for isolated populations. These services and can take a variety of forms such as the Ikon tele-radiology service in Mali. Ikon was developed in 2004 for a 5-year pilot phase by the Malian Society of Medical Imagery (Socit Malienne dImagerie Mdicale, SOMIM), assisted by the International Institute for Communication and Development (lInstitut International pour la Communication et le Dveloppement, IICD). It uses ICT services to transfer and interpret radiology images captured at regional hospitals and health centres, compensating for the absence of radiologists. This concept is being broadened to areas such as tele-dermatology or tele-pathology. In Egypt, Orange has developed a tele-dermatology solution in which a health professional, not necessarily a specialist but located near the patient (e.g. in a dispensary), takes a photo of the dermatological problem and logs details of symptoms as well as age, sex and other data which are sent to a database. Working remotely, medical specialists can register themselves on the site, review symptoms and photos, and establish a diagnosis and treatment plan. Back with the patient, the health worker receives the results on a mobile device and relays them to the patient.

Large medical equipment can be concentrated in a single hospital for an entire country
collection services to monitor chronic illness, alert systems and solutions to enable management of emergencies, created in association with an insurance company or an agent, subscribe to these ideas. A highly relevant example illustrating the potential use of telecoms currently being piloted21, is a microinsurance service offered via mobile phone, coupled with external consultation. This system provides access to medical assistance for a small monthly fee. One element of the service is weekly monitoring delivered via questionnaires (covering weight and medical symptoms), sent to the subscribers mobile phone. Medical experts analyse responses and decide whether a medical consultation is necessary, the cost of which is included in the subscription. A further plan is to implement a tele-payment system enabling users to pay for treatment given to their relatives. This example is currently at test stage (with possible financing from public institutions, as discussed below).

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This achieves three levels of benefit: Time saved for the patient: he/she does not have to travel to a distant hospital, given the travel difficulties encountered in Africa (road quality, state of cars, long distances, etc.). Improved access to medical services: even if training more specialists was a solution, strengthening competences whilst reducing the distance challenge makes up for the lack of specialist resources. Collective benefit: by enabling more direct access to expert advice, medical errors can be reduced23. Another solution is the Psinet remote paediatric diagnosis service, set up in 2007 in Mali, Senegal and Niger. The service is based on regular monitoring of weight curves, plus medical consultations and delivery of standard medicines. Regular monitoring of infant health between 05 years enables conditions to be dealt with swiftly, for the broadest group of people, at an affordable price. The Psinet

Fondation Orange Mali also brought financial support and provided equipment (eight baby scales and six mobile phones). Malian association Kafo Yeredeme Ton is responsible for deploying the service in the field.

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The current challenge is making the system sustainable, particularly regarding its financing model (network, tools, doctor time). Although a large scale benefits study has not yet taken place, the outcomes from these initiatives appear promising as they enable medical assistance and support to be scaled. Two significant limitations remain: The economic model is not yet stable, so support from a public organisation (either directly or via NGOs) remains necessary. Use of ICT is not always suitable for all patients, for example due to illiteracy or time available for questions. Interviews that we were able to conduct with regard to Psinet in Mali illustrate this difficulty24. The solution is of genuine benefit, having saved multiple lives. But it is kept at arms length by volunteers and cannot have 100% coverage if it is limited to people with a mobile phone and an infant. Experience confirms the benefits of tele-medicine solutions, but the economic model remains unstable if it lacks recourse to public financing or foundations25. And e-learning Another potential opportunity concerns staff training, which can also leverage ICT companies to improve the quality of healthcare services. For example the network of health information experts in Uganda26, aimed at health sector workers and implemented through the collaboration of SATELLIFE, Uganda Chartered HealthNet and the Faculty of Medicine of Makere University. The experts network was created in 2003 but the current phase, with ICT companies playing a central part, was started in 2008. Using the cellular telephone network and low-footprint mobile terminals (e.g. personal digital assistants), this network has reduced costs and improved both quality and accessibility of health-related information.

The difficulty is less about technology and more about identifying a viable economic model
service depends on GSM network as it requires agents to visit families and weigh children, using a mobile application to collect and send data (on weight, cough, diarrhoea, fever, vomiting) from the field. An online application linked to a database enables a doctor to monitor children remotely in real-time. The system was developed by a range of private organisations and NGOs/foundations, with the first version financed by partners: Alcatel-Lucent and Afrique Initiatives brought financial support and technical expertise to help initiate the pilot. Mdicament Export contributed to project financing and supplied the stock of medicines required for the duration of the pilot phase.

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The network also equips health workers with a means to collect and distribute information that can improve healthcare, particularly in rural or distant regions. A connection linking Mengo Hospital to Mulago University Hospital enables doctors with different specialties (e.g. surgery, paediatrics, obstetrics and gynaecology) from both units to exchange diagnosis and proposed treatment opinions via transfer of images and patient records. Other projects, incorporating technologies such as WiFi, are being designed to improve health information transmission within five participating districts by enhancing the health information network through the deployment of access points equipped with advanced communications functions. This example is inspiring other countries to develop similar strategies, such as the health information network in Mozambique (MHIN) and the education and health network in Rwanda (RHEIN), both still at a project stage27. A further example is a mobile learning solution incorporating a healthcare module (WapEduc28). This works equally well with students, who gain access to (potentially interactive) educational health content, and health professionals who benefit from sending preventive messages and alerts. The project was borne of the need to capitalise on students use of ICT by broadcasting healthcare related content. Each user needs a mobile phone as available content has been specially formatted for mobiles. A partnership with an healthcare professionals association ensures content relevance, however service sustainability requires local government and (more importantly) health ministry support to validate the content, both in ethical and sometimes legal terms29. E-course content integrates web-based full lessons incorporating a PowerPoint presentation and an audio/video recording of the session, plus seminars and conferences. Archiving for later use is possible, thus 74 lessons were archived in 2008, 54 in 2009 and 16 for the first term of 2010. In March 2010, lesson titles included Acute Seasonal Intestinal obstructions by phytobezoars, Childhood Hydrocephalus, Adult urinary infection: the case of Antananarivo, Type 2 Diabetes: understanding the bases of treatment, Dealing with ophidian

evenomations in Burkina Faso and even a course on ICT and health: Using the Virtual Internet Patient Simulator (VIPS) in French-speaking Africa30. These lessons can be delivered both in Africa but also in Europe. Improve the healthcare infrastructure (telesupport, information flows and monitoring medicines) As well as promoting health insurance and responding to shortfalls in staff, ICT companies, telecoms operators and equipment providers can also help improve healthcare infrastructure, for example by enabling connections between hospitals, improving logistical management of medicines, etc. From deploying a simple telephone number or mobile application to implementing an information system, providers have started a large

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Telecoms operators and equipment providers can also help improve healthcare infrastructure
number of initiatives in recent years to improve the productivity of healthcare services: here we focus on four examples regarding patient registration, information monitoring, hospital life and medicine monitoring. For example, in 2007 Vodacom in South Africa deployed an end-to-end tele-assistance capability for its customers, based on a special number available 24 hours a day. Tele-operators (including second-line doctors) can supply information about transport to health centres, guidance for non-urgent situations, advice in case of trauma, or indeed medical aid. To improve the quality and reach of the medical networks in Rwanda and Tanzania, also in 2007 the GSM Association Development Fund proposed the Phones for Health service with a number of parties (operators and equipment providers). This service enables healthcare workers to use a standard mobile phone, mobile device or PDA,

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Individual ICT companies can lack real strategy around healthcare in Africa
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equipped with an application downloaded on the handset, to upload patients health information on to a central database via a GPRS connection. If the GPRS network is not available, transfers can take place via SMS. The system also incorporates SMS alerts, communications and co-ordination tools aimed at teams in the field who can send medical prescriptions and upload treatment information using the application. Hospitals based in capitals or other cities can also benefit from ICT company assistance, not only via tele-medicine but also through improvements to patient records management, equipment monitoring31 and service delivery. This type of project is being undertaken by better-off countries in Africa, notably in South Africa or the Maghreb region, either in the context of building new towns from scratch (referred to as smart cities32, in particular in the Maghreb region) or private financing for hospitals for medical tourism (Tunisia, Mauritius)33. Such solutions are less widespread in more traditional hospitals. Finally, ICT can help improve productivity across the medical supply chain by automating previously manual (therefore onerous, fastidious and fraudsensitive) information flows. For example, the Kenyan government requested that Telkom Kenya deploy of a system to reduce counterfeiting, fraud and reporting delays in the provisioning34 of antiretroviral therapies35. The solution under construction uses basic operator-provided services over mobile networks to transfer information between participants in the chain dispensaries, logistics management units, central medical depots, district and provincial chemists and indeed, patients. For example a simple line of SMS information enables professionals to be informed quickly about new pharmacological insights, changes in dosage, recommendations in case of epidemic, etc. The system also tackles counterfeiting using by

sending a code via SMS36, proving receipt of the authentic product. Whatever the principal challenges confronting Africas health systems, technical solutions do exist they just need to be deployed. This demands strong support from government, which is the main catalyst to accelerate deployment. Such support is not sufficient by itself however: a number of constraints and limitations specific to healthcare-related ICT projects in Africa also need to be taken into account. With respect to ICT financing, BearingPoints analysis5 of the African health market has shown that patients alone cannot generate sufficient revenues to assure the sustainability of the economic model. Out of the 51 billion dollars spent on healthcare overall, slightly more than a billion dollars are allocated to ICT budgets6. Threshold analysis shows that 47 countries spend less than 50 million dollars, 37 countries less than 10 million dollars, 24 countries less than 5 million dollars and 9 countries less than a million dollars on healthcarerelated ICT. The viability of the model cannot therefore be dependent exclusively on patients. ICT organisations need investment from third parties such as nation-states, or even financial institutions.

Obstacles to ICT for healthcare in Africa

Potential obstacles to healthcare ICT initiatives are not generally to do with the technology once a telecoms network is in place and can deliver the expected baseline in terms of quality of service, that is. The majority of solutions are based on simple tools and protocols such as SMS, which are well-suited for the data transmission requirements of doctors (tele-radiology, telemedicine etc.), and can be straightforward to access from the patients perspective. Limitations are more concerned with how systems are used, access to electricity and finally financing. Patient literacy is a clear hurdle for this type of technology often more for writing than for reading, where numbers and simple words are generally accessible. In African countries with a high official

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rate of illiteracy, certain types of information like medicine posology are therefore sent via USSD, a simple telecoms standard which uses numbers and special characters such as * and #. In Europe, this system is used to access certain operator services but is otherwise rarely used. A greater technological limitation is to do with the regular provisioning and continuity of electricity. Energy access is as much of a challenge for endusers (e.g. for charging batteries) as healthcare providers (continuity of data transfers, never mind broader operations, cold chain requirements for certain medicines, etc.). This hurdle is so great that even telecoms operators consider it when specifying solutions, for example deploying portable solar equipment (costing more than generators) at kiosks used the sale of scratch cards37. In the African context, the final, still-unresolved challenge for ICT companies remains finding an economically viable and sustainable model for these solutions. The success of an ICT healthcare project needs to meet three conditions: a stated requirement issued from a stable and sustainable ecosystem; a relevant ICT solution designed in response; and an economically sustainable model that ensures its viability (both in terms of initial investment and maintenance over time). Financing can come from market dynamics, but the figures in the first section of this report (of a billion dollar market for healthcare-specific ICT across the whole continent) show that it is not enough. Financing from a public aid institution therefore makes sense. While aid strategies have been disputed as being less effective than other means (such as market dynamics or loans) since the success of the book by Dambisa Moyo, Dead Aid38, input from international aid organisations continues to make sense in the healthcare context. However this requires two sets of current aid approaches to be considered and modified. First, healthcare aid projects often finance the initial investment rather than providing support for the duration of the project. Without such support however, the question of financial viability for the term of the ICT project remains. Indeed, given

that ICT solutions are usually proposed by private organisations, the viability and sustainability of each depends on its longer-term profitability. Existing aid may offer a tactical method to compensate for a structurally weak market, but it should also offer concrete routes to financing in the long term. In addition, individual ICT companies can lack real strategy around healthcare in Africa, inhibiting the potential for improved cooperation between parties, or generally coordinated momentum to finance these programmes. Foundations certainly exist: the 189 member-states of the UN are committed to achieving the Millennium Development Goals by 2015, of which three are relevant to healthcare: Reduce infant mortality, Improve Maternal Health, and Combat AIDS, malaria and other diseases. In addition, a range of

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Limitations are more concerned with how systems are used, access to electricity and finally financing
investment opportunities exists across the African healthcare sector. Part of the direct funding for these investments usually comes from governments (e.g. AFD, USAID), from international organisations (e.g. UN, World Bank) and, less often, from private donations (e.g. Bill and Melinda Gates Foundation). Beyond declarations of intent however, no truly coherent policy exists for financing healthcare projects in general, nor their ICT dimension in particular. Participants are numerous but they do not work together on targeted countries or illnesses, nor the selected financing mechanisms39. By moving beyond this dual constraint (the need for long-term rather than seed financing and the lack of coordinated strategy), a way forward for greater effectiveness in the deployment of ICT companies can be achieved to the benefit of healthcare in Africa.

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mHealth Alliance best practices in 2011 The mHealth Alliance promotes using mobile technologies to improve healthcare throughout the world, across a number of sectors. Working with a diverse range of partners, the alliance brings the mHealth community together to overcome common challenges by sharing tools, knowledge, experience and best practice. The mHealth Alliance advocates for more high quality research and study to grow the evidence base; seeks to build capacity across health and industry decision-makers, managers, and practitioners; promotes sustainable business models; and supports systems integration by advocating the standardization and interoperability of mHealth platforms. The winning Top 11 innovators in the 2011 Innovators Challenge at the mHealth Summit are: 1) mCare an integrated mobile system facilitating pregnancy surveillance and registration to optimize care delivery to pregnant women and new-borns, and facilitates emergency response. 2) Pesinet a system combining local resources and mobile technology to increase care and reduce child mortality in Mali. 3) Voice Net a personalized voice-based information retrieval and transaction system with local language voice recognition to effectively aid healthcare delivery in India. 4) Cost-effective and field-portable microscope and diagnostics tools for telemedicine application in resource-poor areas and developing countries in Africa, South America, and South Asia. 5) mPedigree a platform to combine mobile technology and cloud computing to fight counterfeit medicines by providing free access to an instant drug quality verification system via text messaging in Africa and South Asia. 6) CommCare-Sense a localized multimedia system to improve quality of care in four districts in India 7) MDNet a networking program for physicians in Ghana and Liberia, allowing physicians to call and text each other at no cost, leading to the first-ever doctor directories and a bulk SMS system through which government administrators can send alerts and collect data. 8) An application that enables menu-driven applications to run directly from a SIM card on even the least expensive phones in Malawi and Cameroon. 9) MiDoctor a system that allows to address problems associated with non-communicable diseases in low-resource settings by connecting patients and their providers via automated phone calls and SIM messages, alerting clinical staff of high-risk situations for patients, and contributing to electronic medical records. 10) A mother and child tracking system, based on SMS technology that provides updates from auxiliary nurse midwives in India. 11) AMPATH a clinical decision-support system that incorporates patient data within electronic health records to provide patient-specific and timely reminders about deficiencies in care to clinicians in Kenya.

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Conclusion
Health-related issues remain more critical in Africa than in any other continent as the mortality gap, with the level of pandemics on one hand and resources on the other hand, continues to widen. ICT companies bring elements of the solution: they compensate in part for a lack of technical and human resources, promoting data exchange to enable medical investment and expertise to be concentrated in fewer locations. Once networks are in place, this sharing of resources enables significant productivity gains as maintenance costs are low and the obsolescence of ICT is slower than for medical resources.

Health-related issues remain more critical in Africa than in any other continent
Aid funds add value particularly in early stages, but they cannot respond to the comprehensive set of needs across the duration of programmes, either macro-economically, as Dambisa Moyo proved40, or to support the monitoring of patients daily activities which requires the broader solvency of Africas health sector. ICT companies can offer significant help to Africas health sector (maybe a great deal more to what they provide in developed countries, in relative terms). However the challenges to overcome (chronic low equipment levels, the brain drain loss of medical practitioners to Europe and the Middle East, the scale of health crises, the lack of a genuine system of shared financing) mean that ICT can only offer a partial solution. As the m-payment example shows however, technology can help identify new solutions by aligning with the behaviours of the populations concerned. State-led, generalised therapeutic policies do not always match specific patients needs and habits: ICT companies can help address these needs.

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Technology can help identify new solutions by aligning with the behaviours of the populations concerned
The question of financing remains unresolved, however. As on other continents, ICT solutions in Africa are delivered by private companies that ensure upgrades and continued development of the technologies concerned. Even in Africa, ICT service quality needs to be maintained and continuously improved, requiring constant attention from those driving health projects. It is therefore crucial to identify sustainable financing mechanisms.

ICT and health systems in Africa

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About the authors

Jean-Michel Huet is a Director at BearingPoints Paris office. He works on different issues relating to marketing and international development of telecoms, media and utilities companies. He has published numerous articles and point of views on entry strategies, management and convergence, including books (Le meilleur de la stratgie et du management, Village Mondial, 2009; What if telecoms were the key to the third industrial revolution?, Pearson, 2010). Prior to joining BearingPoint, Jean-Michel was a Product Manager at France Tlcom and worked at a consulting firm. He is a graduate of Reims Management School and Sciences Po Paris. jean-michel.huet@bearingpointinstitute.com

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Tariq Ashraf is a Manager within BearingPoints Communications, Media and Entertainment practice in Paris and has 10 years consulting experience in the telecoms industry. He has business strategy as well as strategic marketing expertise (service offering definition/ cartography, strategic product roadmap definition). Tariq has conducted multiple market research and market study assignments and has an international profile, serving clients in Europe, North America and North Africa as well as in India. tariq.ashraf@bearingpointinstitute.com

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ICT and health systems in Africa

Sources
1 For more detailed analysis TIC et systmes de sant en Afrique, Note Ifri, mai 2010 in Tcheng, Henri, Huet, JeanMichel, Romdhane, Mouna, The WHO reported, based on analysis of empirical data, that the relationship between GNP per inhabitant and total health spending followed the following equation: Total health spending/inhab. = 0.0383*GNP/inhab. 0.249 with a margin of error of 5%, redcuing to 2% for countries in the zone Africa/Middle-East. Source: IFC, World Bank, The Business of Health in Africa: Partnering with the Private Sector to Improve Peoples Lives, 138 pages, 2007 BearingPoint Analysis, 2010, based on data from the IMF, World Bank, OECD, United Nations Conference for trade and development, European Bank for Reconstruction and Development, UN, Deutsche Bank, Merill Lynch, JP Morgan, Morgan Stanley, Goldman Sachs, Oxford Economics, Feri et Consensus Forecasts, French economic missions, governments and central banks. IFC, World Bank, The Business of Health in Africa: Partnering with the Private Sector to Improve Peoples Lives, 138 pages, 2007. The International Finance Corporation (IFC), an organisation of the World Bank charged with encouraging economic development of countries via financing of private sector projects. The IFC invests about 1.5 billion dollars per year in Africa, particularly in ICT and health. BearingPoint Analysis, 2010, op. cit. Or rounding up, one dollar per person, per year. We estimate that this figure is 60 times greater in France. H. Tcheng, J-M. Huet, op. cit. Relevant insurance model is a topic on its own beyond the scope of this study. The social security system could be a solution (Tunisia is following this route, for example) but in sub-Saharan Africa (for example Senegal) mutual companies are the most promising. In practice, separation between the medical treatment and payment reduces consumption frictions.,: B. Fantino, G. Ropert, Le systme de sant en France, Paris, Dunod, 2008, 358 pages

interventions, namely vaccination of children under 1 year old against measles, and births assisted by qualified health personnel, for at least 80% of the population. This indicator is generally called the WHO threshold. The rate is from 11 in Europe and from 1.44 in sub-Saharan Africa. (source: IFC, World Bank, op .cit.). the breakdown of this latter figure is shown in the graph number of medical resources per 1000 inhabitants. 14 IFC, World Bank, op. cit. 15 Source : BearingPoint interviews in 2008 and 2009, plus H. Tcheng, J-M. Huet, Les TIC pour aider pallier les faiblesses de la sant en Afrique , Tlcoms, n 200, p. 70 72, June 2009. 16 WHO, World Health Report - Health systems: Improving performance; WHO, reports between 2001 and 2007. 17 Metronidazole is an antibiotic and antiparisitic treatment 18 Molecule involved in the treatment of pulmonary tuberculosis. 19 From a western county standpoint, access to location and hours of dispensaries may appear secondary but it is key from a a African countries local economy perspective. By way of example, one part of this information, easily accessible in Europe, is not so in Africa due to the absence of a universal telecoms service. Universal service collects a set of services giving easy access to telecoms services including where those are not economically viable. in France for example, Universal Service allowed the financing of telephone cabins in towns with less than 20,000 residents, directory enquiry services, telephone directories, etc., all of which services that Europeans would expect to see but which are missing on the African continent. 20 Elements presented below are those which are available. A major part of these projects is in fact in development with strong confidentiality clauses attached. Authors do present principles which they are able to communicate and that are which are proven today in specific projects exact figures, which are confidential. 21 Experiments will take place in 2010 or 2011 in West African countries within the context of public-private financing. 22 BearingPoint Interviews , 2008 et 2009. 23 20 examples from Timbuktu in the first year of function for IKON. By way of example, the case of radiography of a hand which happened at a patients home in Mopti for mundane reasons. It shows an image called built by the bone spans at the level of one of the metacarpals. For the doctors at the level of Mopti, it had been taken for a bone lesion and a costly and dangerous operation had been envisaged. Radio pictures sent by the new system to the specialists enabled a radiologist in Bamako to see that it was, quite simply, a less grave variant. (Source : The International Institution for Communication and Development (lInstitut International pour la Communication et le Dveloppement, IICD, 2010 http://www.iicd.org).

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5 6 7 8

10 WHO, World Health Report - Health systems: Improving performance, 2008. See also WHO, The Health of the People: The African Regional Health Report, 2006. 11 Effect of mutual packages remains limited because it covers only employees of larger companies or administrative organisations, which does not make up the majority of employment in these countries. 12 Death rate shows the incidence and the prevalence of illnesses on the population at a global level. It is often confused with the mortality rate (Number of deaths across the population related to illness) 13 The Anand Baernighausen regression shows that 2.5 health workers for 1000 inhabitants are needed to ensure two basic

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ICT and health systems in Africa

24 BearingPoint Interviews, 2008, 2009. 25 Several records of tele-medicine financing by USAID, for example. 26 Uganda Health Information Network (UHIN). 27 Source : International Development Research Center, IDRC, 2010 http://www.idrc.ca/en/ev-1-201-1-DO_TOPIC.html 28 WapEduc was launched in France first of all as a mobile phone education system. Its creator, Philippe Steger decided in 2009 to extend his service to African countries. The first pilot country is Senegal. 29 Mmore details on technology options linked to education in Africa, read Tcheng, H., Huet, J-M., Romdhane, M., Roubaud, J., Le tl-enseignement, un espoir pour lAfrique ?, Journal des tlcoms, , n 200, p. 55, October 2009. In particular, regarding population awareness, training issues and broadcasting of best practices or simple techniques in health promoted by the WHO and UNICEF, it is shown that ICT companies can bring media, in particular radio and mobile telephony which are the two terminals the most widespread in Africa (radio in rural locations, mobile telephony in urban areas, other means such as television or the PC lagging far behind). 30 Source: RAFT, 2010. This last course indeed covers the use of a computer simulator for continued medical training and help to isolated healthcare professionals in Africa. (Course delivered by Caroline Coquoz and Georges Bediang (Geneva University Hospitals) on Thursday 18 March 2010 at 11.00 GMT link to access course: http://www.dudal.net/dudal/apps/jws/uiclient?/raft/ suisse/20100318_1100). 31 A BearingPoint study in 2009 involving several hospital managers showed a major loss of time linked to searching for lost trolleys within the same hospitals. 32 The smart city concept refers to constructing towns that incorporate the generalised use of new technologies. The majority of these intelligent, indeed futuristic city projects are financed by Gulf investors . Some smart cities are present in all or part as true medical cities (in Tunisia or Morocco but mainly in the, in Jordan, and GCC countries such as Qatar or UAE-Dubai) and it is the set of health-related benefits, air quality, post-operative convalescence, care for older people that is put first. Telecoms operators should bring technology that powers this cities (Connections between and within hospitals, from tracing medicines to calling a nurse and including video on demand packages in rooms). Strictly speaking, these projects follow logic closer to tourism than healthcare but are worth mentioning. 33 Medical centres for rich tourists in the GCC region or in Europe which want to benefit from recovery from an operation in a sunny environment. This practice, widespread in several countries, does exist , but is is not covered in this research note.

34 BearingPoint, 2009. 35 BearingPoint, 2009. 36 Or in a more sophisticated manner that is also better adapted to central depots via 2D bar codes which enable an accurate trace of product information. 37 D. Florin, J.-M. Huet, Le dveloppement par lnergie solaire , Les Echos, January 2009. 38 D. Moyo, Dead Aid: Why Aid is Not Working and How There is Another Way for Africa, Allen Lane, 190 pages. Criticisms were made regarding this release. The two most relevant are in the context of our works: on one side, principles posed in this release become generic (aid in the wider sense); on the other hand, by viewing a privatisation of aid, the dimension of universal cover disappears in the context of healthcare or this coverage/universal service becomes a key dimension. 39 Source: interviews conducted by BearingPoint in the first quarter of 2009 40 D. Moyo, op. cit.

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ICT and health systems in Africa

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References
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Web references
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