ICTs and health in Uganda: benefits, challenges and contradictions

Background

Information & communications technologies (ICTs) are continually viewed as having the potential to address several challenges in Africa including in the health sector. It however ought to be noted that the medical sector has utilised communication technologies to diagnose patients for ages. In the 1970s for instance, Thomas Bird coined the term ‘Telemedicine’ to refer to long distance health care. In this case, physicians examined patients from a distance using telecommunications technologies.

With the convergence of ICTs, telemedicine is becoming even more common. Several projects can be found in developing countries like Uganda that aim to transport health information and services through ICTs. ICTs are considered faster and less expensive than transporting either patients or doctors. They are also said to enhance access to more accurate and timely information as opposed to the manual systems of storing and transferring information that are still commonly used in several hospitals in Uganda.

Telemedicine could involve the use of computers, personal digital assistants (PDA), telephone (both fixed and mobile) and fax machines amongst others (Huston and Huston 2000).  Maxfield (2004) further groups ICT applications available in the area of health into the following four categories:

1. ICT-enabled applications that encourage wider diffusion of health information from formal (e.g., community health workers) or informal (e.g., health opinion leaders) sources.


2. The use of the internet to enable advocacy coalition members to interact online, develop a shared identity and common agenda, exchange information, and mobilise to collective action. Furthermore, offline activities can also be coordinated via SMS (mobile phone text messages).


3. The use of ICTs for distance education to enhance the traditional face-to-face TOT (training of trainers) model, while fostering networks that trainees can rely on as a resource when they return to the field.


4. Integration of new ICTs (e.g., computers and the web) into programs utilising traditional ICTs (e.g., radio, telephones and print) to increase the scale or scope of programs.
   

For Sub-Saharan Africa, ICTs could offer a great deal of benefits since health care is one of its fundamental needs. Health challenges in Africa include both the diseases and supporting facilities in terms of human resource and physical infrastructure. For instance, HIV/AIDS, Malaria, Cholera, typhoid, and yellow fever are reported to kill several people in Africa each year. According to the 2006 World Health Organisation report, 70% of all those infected with HIV/AIDS are in Sub-Saharan Africa. Shortage of health personnel is also a key problem in Africa that the use of ICTs could address. Most doctors are located in urban areas and very few of these are specialists. With ICTs they could be able to consult with others even outside of Africa in real time. ICTs are also important for both health providers and patients in establishing people’s blood serology.

However, limited infrastructural facilities can pose challenges to implementing telemedicine. This is especially so in disseminating and providing access to information for those working on disease like HIV/AIDS. In Uganda, more ‘traditional’ ICTs like radio and television have been used to educate the public on HIV/AIDS prevention and treatment, polio immunisation and malaria prevention, through short messages, talk shows and plays, including various programmes targeting the youth. There is a need to extend these initiatives to more recent ICTs like computers, emails and the internet not just for the elite, but also for everyday people.

The use of communications technologies in the medical sector however presents certain challenges and contradictions. For instance, ultra-sound machines, while useful for monitoring the growth and development of foetuses, have also been used in countries like China and India towards infanticide. Cases have been reported where the sex-selected abortions are made. In most instances, female babies are aborted because they are regarded the less important sex (Gendercide 2006). This is clearly an element of gender discrimination worth further discussion but is beyond the scope of this paper.

The use of ICTs for health also faces cost and infrastructural challenges. Not all medical units are computerised and this makes it hard to implement telemedicine plans as proposed in Uganda’s ICT policy. This paper will examine how ICTs have worked for the health sector through an examination of the ‘Satellife’ project in Uganda, as well as policy provisions for ICTs and health.



A brief on the case studies: ICTs for health provisions in Uganda



The government of Uganda endeavours to incorporate ICTs into the health sector through several policies. Through the National ICT Policy, the government of Uganda considers the incorporation of ICTs into the health sector. Additionally, the Poverty Eradication Action Plan (PEAP) identifies ICTs as key to the country’s modernisation and development. Through the Ministry of Health (MOH)’s Health Sector Strategic Plan (HSSP), the government embraces ICT as a tool for enhancing the quality of health care service delivery, and a health sector ICT policy, strategies and action plans have been developed (WOUGNET 2004).

The Satellife PDA project

                       

Figure 1: the workings of the Satellife PDA project in Uganda

Source: I-Network Newsletter 2003:3 and 4

The Satellife PDA project was implemented in Ghana, Kenya and Uganda. The aim of the project was to demonstrate the viability of Personal Digital Assistants (PDAs) - also known as handheld computers - for addressing the digital divide among health professionals in Africa. The project linked health professionals to each other and to reliable sources of information, including modem to modem telephone links and the internet using geostationary satellites.

The aim of the satellife project was to explore questions related to the selection and design of appropriate, affordable technology and locally relevant content for use in African healthcare environment. The project specially targeted assessing the usefulness of the PDA’s for data collection and information dissemination. The PDAs were tested in the daily work environments of physicians, medical officers and medical students. This was to gain a perspective on the real issues that affect the adoption of ICTs in the health environment. ICTs were therefore used to collect health information to support decision making, improving Doctor’s access to current medical information, linking healthcare professionals so they could share information and knowledge and enhance health administration, remote diagnostics and distribution of medical supplies.

In Uganda, the project tested the use and usefulness of PDAs by medical practitioners to conduct an epidemiological survey on malaria and to access and use medical reference tools and texts. The Uganda project was implemented by the Makerere University Medical School and Healthnet Uganda and funded by the International Development Research Centre (IDRC), Canada.

The benefits, challenges and contradictions of adopting ICTs for health

ICTs have enabled doctors to do remote consultations and diagnosis, access medical information and coordinate research more effectively. More traditional ICTs like radio and television have been beneficial in disease prevention and epidemic response. In Uganda, this has been evident in response to HIV/AIDS, Malaria and Cholera amongst other diseases. More recent ICTs like mobile phones, email and the internet could also be used for health alerts to the general public and medical consultations.

Collaboration is possible between physicians within and between medical sites. Physicians consulted each other on patient treatment and this helped reduce the number of referral cases to main hospitals. Patients were then able to cut transport costs and unnecessary journeys that could result in further harm, especially to patients who are terminally ill.

 

Data collection and research was also possible at a more cost effective form. Using the PDAs, email and going straight to the internet helped cuts initial costs spent on travel in the process of data collection.

Through the project, remote mentoring/teaching was possible. ICTs enabled training in skills from one hospital to another for instance between Mulago hospital and Butabika mental hospital in relation to psychiatry.

ICTs have also enabled tele-homecare. Patients can now consult doctors via the telephone (call or SMS) or email. Several patients use the mobile phone and SMS to book appointments to meet their doctors, call for emergency services in case of accidents and even set reminders for taking medication.

ICTs also enable distance learning for health personnel and others interesting in researching on several health issues. There are several sites available giving information HIV/AIDS and other diseases like Malaria. Further information can be shared through radio and television or on CD ROMS, by email or teleconferencing.

Challenges and contradictions

Although ICTs has the potential to be greatly beneficial for the health sector of a developing country, its success is sometimes marred by challenges and contradictions. This includes the workable condition and costs of ICT equipment, level of awareness and skills of the potential users, technology compatibility and policy provisions amongst others.

The poor ICT infrastructure status in Uganda currently is unable to adequately support the potential benefits of ICTs in the health sector. Very few hospitals are computerised, and when they are, internet access is limited. Most hospitals, including big national hospitals like the Mulago hospital, still use manual systems of recording and storing patient information. 

Cost of accessing the internet, maintaining the equipment and buying new ones is also a challenge. In other cases costs of installing internet facilities and maintaining it is also as challenge for poor countries like Uganda.

In addition to the costs and status of infrastructure, several hospitals fail to work together because of the incompatibility of equipment and software. Related to this is the presence and availability of experts in real time. In cases where consultations have to be made across continents, there is also the issue of time difference and presence of experts when they are required.

Most of the information available on the internet is in English or in languages not accessible to the wider segments of the population. For those who can access English, there is the challenge of understanding medical jargon used in most of these sites.

The project implementation was further slowed down when the Uganda Revenue Authority (URA), confiscated project equipment and delayed releasing them. This action contradicts the policy provisions that provide tax exemptions on ICT-related equipment coming into the country. There is therefore, a disconnect between what stated government intentions and what actually happens. This also illuminates the process which the Ugandan government disseminates information on newly passed policies and how implementation is ensured. Some government officials and departments are sometimes not aware of new passed policies and laws.

The gender dimension of the project

Despite the benefits of the Satellife project, there is a need for a gender analysis. According to Longwe (1991), a project may be considered negative, neutral or positive depending how many women participate in it:  a project is considered be negative if it does not involve women at all; it is neutral if it recognises women; and positive if considers women’s issues in its design and implementation.

In relation to this framework, the Satellife project can be said to be neutral. Although the project did not specifically target women, women are known to have participated. At the project team level, at least two women doctors were involved. However, the level of decision-making that these female doctors had in the project is not documented. It is therefore difficult to establish the level of influence they had in shaping and directing the project, and if their presence made a difference in terms consideration of gender issues. A further study, involving an in-depth interview with these women doctors would therefore be helpful in establishing what happened.

In addition, it would be necessary to analyse the number of women who participated in the project at the lower levels, including at the technical and beneficiary levels. This would allow analysis on the points of access according to gender, attitudes towards ICTs within the health sector, differences in frequency of use by men and women, and importantly, the relationship between gender, access and attitude. Unfortunately, there are currently insufficient information available to enable this kind of analysis. Most of the information on user-patterns is not gender disaggregated. This is a common aspect found in most project reports that do not pay particular attention to gender.

In terms of capacity building for the project staff, training was offered in some occasions but the documentations indicate that only male staff went for training (see the Healthnet technical report of 2004:14-16 at http://www.healthnet.org/idrcreport.html)

Conclusion

The extent to which the health sector of any country is computerised and the extent of use of other ICTs is telling of the extent to which ICT benefits can be enjoyed in their health sector. An assessment of the projects indicates that Uganda needs to do more to benefit from the benefits of ICTs for health. For while ICTs offer a variety of opportunities, efforts have to be made in order to systematically harness the underlying potentials and opportunities. This is especially in terms of understanding the gender dimensions of particular projects to ensure that different issues, needs and concerns by different sections of society are adequately addressed. ICTs also need to be used to address several medical challenges and diseases especially HIV/AIDS.

References

Adeya, N. C. (2003) ICTs and poverty: a literature review, IDRC

Gendercide (2006) Case study: female infanticide: focus on India and China. Available at http://www.gendercide.org/case_infanticide.html (25th March 2006)

Huston, T.  and Huston, J.  (2000)  Is TeleMedicine a practical reality? Communications of the ACM, 43 (6):91-95

ITU (2000)  TeleMedicine and Developing Countries.  Telecommunications Development Bureau, Document 2/116, Geneva: International Telecommunications Union (ITU)

Kasozi, M. and Nkuuhe, J. (2003) Uganda Chartered Healthnet promotes healthcare using PDAs. In I-Network Uganda, a quarterly Newsletter of I-network Uganda: ICTs in health, 2(4): 3-4

Longwe, S. H (1991)  Gender awareness: the missing elements in the Third World development project. In Wallace, T. with March, C. (eds.) Changing perceptions: writings on gender and development. Oxford, Oxfam.

Maxfield, A. (June 2004). Information and communication technologies for the developing world. Health Communication Insights. Baltimore: Health Communication Partnership based at John Hopkins Bloomberg School of Public Health / Center for Communication Programs.

WOUGNET (2004) Women’s health: the role of ICTs. Report of a workshop held on 19 August 2004 at Hotel Africana, Kampala, Uganda.