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Best Practices for Building an Integrated National Health Information System: Rwanda.

Author(s) Caricia Catalani1, Angela Hoth2, Dawn Seymour3, Tyler Nelson 4, Felix Kayigamba 5, Richard Gakuba6
Affiliation(s) 1Innovative Support to Emergency, Disease, & Disaster (InSTEDD) & University of California, Berkeley, School of Public Health, San Francisco, United States, 2Innovative Support to Emergency, Disease, & Disaster (InSTEDD), Berkeley, United States, 3Rwanda Health Information Exchange, Regenstrief Institute, Kigali, Rwanda, 4Maternal Health & RapidSMS, The Access Project, Kigali, Rwanda, 5The Access Project, Kigali, Rwanda, 6 Rwanda Health Information Exchange , Kigali, Rwanda
Country - ies of focus Rwanda
Relevant to the conference tracks Innovation and Technologies
Summary The Rwanda Health Information Exchange (RHIE) is among the world’s first efforts to establish an integrated national health information system in a low-resource setting. Global decision-makers and implementers can benefit from both RHIE's open source tools and knowledge of leading and managing innovation for integration. This study assesses best practices in the design, development, and deployment of RHIE from the perspective of key stakeholders. Themes from the analysis of semi-structured interviews with funders, leaders, and implementers include recommendations on governance of country-owned initiatives, technological design and development, and deployment in a low-resource setting.
Background RHIE is a cloud-based system that supports quality of care and continuity of care over time, across geographies, and across different care delivery sites. RHIE’s vision is to improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different information systems used nationwide. In 2010, RHIE was designed and developed under the leadership of Rwanda’s Ministry of Health by the Open Health Information Exchange (OpenHIE), a global open-source technology community including partners at PEPFAR, Canadian International Research Development Center, Rockefeller Foundation, Regenstrief Institute, InSTEDD, Jembi Health Systems, IntraHealth, and others. RHIE’s national rollout began in 2012 and entailed working across sites with minimal infrastructure and among providers with little computer experience to configure hardware, install software, build local capacity, and manage technical support . Today, and as scale-up continues, RHIE facilitates the movement of health information across Rwanda with the primary aim of improving maternal and child health and the treatment and prevention of HIV/AIDS.
Objectives The Open Health Information Exchange builds free and open-source tools to enable other national leaders, policymakers, and implementers to improve the integration of health data and systems through the establishment of health information exchanges. Today, the partnership is collaborating with national leaders from six countries, providing technical support required to spearhead this effort. However, more than just tools and technical support, decision-makers need practical insights into the process of leading and managing innovation of this kind. As such, this study aims to describe the best practices in design, development, and deployment of a health information exchange, based on the RHIE experience. Researchers conducted key stakeholder interviews among RHIE funders, leaders, and implementers with a range of expertise from computer engineering to health systems management to clinical care. From their critical reflections of the RHIE initiative, its three years of history, and its pathways forward, stakeholders provide recommendations on approaches to governance of country-owned initiatives, strategies for technological design and development, and tactics for managing deployment of technological innovation in low-resource settings.
Methodology Qualitative semi-structured interviews were conducted with RHIE key stakeholders. Stakeholders included Ministry of Health leaders & implementers, project managers & strategists, technology architecture designers & developers, and funders & other institutional partners. Semi-structured interviews guided a conversational interview, providing the interviewers with key points of discussion without requiring strict adherence to a set order of questioning or phrasing of the questions. As such, interviewees provide descriptions of their experiences, ideas, and critiques in an open and guided discussion. Interview were conducted by two trained interviewers via phone, audio-recorded, and documented through detailed notes. Interview duration ranged from 45-75 minutes. Analysis was conducted using Dedoose Mixed Methods Analysis Software, a cloud-based research and analysis application. A modified grounded theory approach was used in the analysis of qualitative data. This approach facilitated the detailed and systematic examination of data regularities in the relationships between and within codes, and for variations and contrasts within codes. Major themes emerged from the codes and a descriptive framework formed.
Results Key stakeholder interviews included 14 participants from 7 organizations and 4 countries. Several key themes emerged across the major phases, spanning partnership building, design, development, deployment, and evaluation. First, eHealth is a new field without established guidelines for management and leadership and, as such, most found it challenging to partner without clearly articulated governance rules. Terms of governance, they argued, provide guidance for decision-making, roles and responsibilities, accountability, and transparency. The RHIE experience confirmed for most that country-ownership of the initiative should be established early and embedded into the partnership’s governance structures.Second, most partners commented on the difficulty of collaboration when key contributors were spread across several countries and time-zones. They explained that in a low-resource setting, it is often necessary to look for eHealth integration expertise and capacity from people based in other countries. Cross-cultural, cross-national, and cross-disciplinary communication was immensely difficult, although building an integrated system required a well-integrated team. Stakeholders found that it was critical to have a shared commitment to regular communication and ample budget for in-person meetings.Third, experts were adamant that an eHealth integration initiative should start by looking at existing, tested, and ideally open-source tools that might serve as customizable building blocks for their own solution. While identifying these tools, most argued that the team must create a shared standard of assessment so that they can transparently evaluate tools in a world where business interests may sway these decisions. Many stakeholders shared the opinion that eHealth solutions must be simple, tested, and even boring, although “the siren song is to do something new, bold, and innovative.”Finally, most partners found that the health and human development objectives of the project were obfuscated by the technological objectives of the project. RHIE contributors spent the vast majority of their efforts on designing and developing the technology, often without a shared vision of how the system would ultimately impact health services, morbidity, and mortality. One expert argued that it should have been the opposite and that “in a sociotechnical system, the technical should be 10% and the rest of the money and time should be spent focusing on implementing.”
Conclusion The health systems integration experts involved in RHIE shared a common sense of the challenges and opportunities inherent in partnering, designing, developing, and deploying a health information exchange. Several best practices emerge from these findings: establish rules of governance to guide the partnership; plan for regular and in-person communications to facilitate collaboration among diverse contributors; build on existing, tested, and open-source technologies before considering anything new; and, create a shared strategic and practical vision for how a new eHealth tool will impact health. As the OpenHIE expands beyond Rwanda and into new country implementations, these findings can be used to guide policy-makers, implementers, and other experts. Worldwide, country leaders are struggling to take advantage of the digitization of health information while managing innovation within health centers and protecting patient privacy. In an era of big data, health information exchange is one way to integrate and manage health information across disparate systems. Health information exchange tools and best practices may improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different health information devices, tools, and systems emerging worldwide.

Modelling potential distribution of current and future malaria in Tanzania: An Ecological Niche framework

Author(s) Benjamin Mayala1, Leonard Mboera2, Edwin Michael3
Affiliation(s) 1Disease Surveillance and GIS, National INstitute for Medical Research, Dar es Salaam , Tanzania, 2ICT, NIMR, Dar es Salaam, Tanzania, 3Department of Biological Sciences, University of Notre Dame, Notre Dame, United States.
Country - ies of focus Tanzania
Relevant to the conference tracks Innovation and Technologies
Summary Malaria is endemic in most parts of Tanzania and remains a major cause of morbidity and mortality both in rural and urban areas. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of various species. The application of such tool is very limited in predicting the potential distribution of diseases, especially when using occurrence (presence). In this study an ensemble model approach was employed to predict the current and future (2050) potential distribution of malaria in Tanzania. The ensemble approach demonstrated an enhanced prediction model compared to the individual model outputs.
Background Malaria is a leading cause of morbidity and mortality accounting for over 30% of the disease burden in Tanzania. Over 95% of the 37.4 million people in the country are at risk of malaria infection. Various factors account for malaria in Tanzania, which include demographic factors, socioeconomic factors, weak health systems, a limited budget, poor governance and accountability, antimalarial drug and insecticide resistance, environmental and climate change, vector migration, and land use patterns. Efforts have been employed to reduce malaria in Tanzania, which include insecticide treated mosquito nets, indoor residual spraying, improved diagnosis by microscopy and rapid diagnostic tests, effective treatment of cases, and implementation of intermittent presumptive treatment of pregnant women. In spite of the many efforts to combat malaria, the disease remains a leading public health problem in most parts of the country. Climate conditions such as precipitation, temperature, and relative humidity have a substantial impact on malaria. Despite the importance of these factors to the distribution of malaria, limited studies have been undertaken to address the association between climatic conditions and malaria epidemics.
Objectives Previous attempts to map the geographical distribution of malaria have focused on a theoretical model that is based on available long-term climate data, as well as empirical models that fit malaria data to environmental factors to predict the number of months during which transmission is possible. These studies have not demonstrated the predictive ability beyond the input data area. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of species. It has been applied to diseases to assess the potential distribution of vectors. Applications of ENM to study the distribution of malaria using occurrence cases are limited in Tanzania. Here, we adapt modelling techniques, to predict the current and future potential distribution of malaria. The goals of the study were to (i) identify possible distribution areas of malaria using an ensemble approach that integrate multiple individual models to generate a better and more conservative overall solution, (ii) identify the environmental and climate conditions correlated with malaria occurrences, estimate the population at risk, and (iii) determine how future climate change may affect the distribution of malaria in Tanzania.
Methodology Data: Malaria occurrence point data were obtained from the Ministry of Health and Social Welfare. These are reported cases from various health facilities in the country. The Current and future (2050) environmental data used in our study were obtained from CliMond gridded climate data, which represents an improvement on the existing global climate data available for bioclimatic modelling. Thirteen environmental variables were used from CliMond; this included eight bioclimatic variables, monthly minimum and maximum temperatures, monthly precipitation, monthly altitude and relative humidity. The 8-bioclimatic variables were mean temperature of wettest quarter, mean temperature of driest quarter, mean temperature of warmest quarter, mean temperature of coldest quarter, precipitation of wettest quarter, precipitation of driest quarter, precipitation of warmest quarter, and precipitation of coldest quarter. The study also included other variables such as human population density and normalised difference vegetation index (NDVI). To avoid fitting the model into too many environmental variables, we extracted the environmental information from each presence data and performed a Pearson correlation tests to see if any of the layers were too similar to include in a model together.
Data Processing: The environmental data used for model development were imported into ArcGIS 10.1 software in which they were re-projected to the same coordinate system, clipped to an area encompassing the administrative boundaries of Tanzania, resampled to obtain the same pixel resolution of 5km, extracted to obtain same dimensions, and converted to ASCII format.
Models development: We considered eight modeling algorithms for the ENM development, GAM, GLM, GBM, MAXENT, MARS and RF were implemented in biomod2 package in Revolution R software, SVM using dismo package and GARP using a Desktop GARP.
Ensemble Model Prediction: An ensemble approach was adapted in our study by combining the eight model output through a weighted average using two thresholds (i) the 5th percentile of the training presence (5% TP) and (ii) the least training presence (LTP).
To estimate the populations at risk of malaria, we reclassified the ensemble model outputs to binary maps (which have pixel values of 0 - no malaria and 1 - malaria present) using the two thresholds - 5% TP and LPT. ArcGIS tools were used to compute the population and districts predicted at risk to malaria
Results The overall contribution of each environmental variable to all the models ranged from 2% to 62%. Population density was the main variables influencing the potential distribution of malaria in all the models. Relative humidity contributed 10.5% to the model followed by altitude (10%) and precipitation of driest quarter (5.4%). The other variables had less influence. The prediction maps revealed that almost the whole country is endemic for malaria. However, the probability of malaria presence varies spatially. All the models depicted high probability (0.5 or greater) of occurrence of malaria in the east and south coast of Indian Ocean, north regions and along Lake Victoria. The models depicted a medium probability of malaria occurrence along the central and west regions. The ensemble model at 5% TP threshold demonstrated high occurrence of malaria in the east, coast of Indian Ocean, north regions and along Lake Victoria, a pattern from east to central, then low occurrence from central to west and also south parts of the country
The ensemble model future (2050) prediction at 5% TP threshold showed an increase/shift of malaria occurrence in the northern part and towards the central part of the country is expected. High percentage of malaria occurrence is predicted in the southern highlands and southern regions of the country. Some areas are predicted with low percentage occurrence in the central regions and areas in the west of the country. Areas in the north, around Lake Victoria and along the coast of Indian Ocean are predicted to maintain the highest percentage of malaria occurrence.
The current population at risk of malaria is estimated to be 29 and 34 million, and this could rise in the future to 81.58 and 93.7 million. About 79% of the districts are at high risk for malaria, which is predicted to increase to 84% in future
Conclusion A link between climate change and malaria has been described previously; particularly temperature and rainfall are mentioned as the major variables contributing to malaria distribution. The present study, however, shows a lesser contribution of temperature and rainfall in the development of the models, as compared to population density, which depicted the highest contribution. This suggest that (i) population density is the key variable in malaria and (ii) malaria cannot necessary be caused by climate variables, as they may exhibit a smaller role in determining the ecological niche and hence the potential distribution of malaria. However, despite the potential influence of the population variable shown in our model outputs, it is then clear that population density, environmental variables and other factors (than those we used) will need to be included in studies attempting to model malaria endemicity.
Our findings showed high percentage areas predicted by the ensemble for both current and future - 2050, whereas individual models resulted into low predicted areas. The results suggest that ensemble model predictions are more robust than the predictions from individual models.
An important implication of our model is that the predicted distribution of malaria in the various districts in Tanzania can inform the selection of locally appropriate control interventions. The malaria control program can plan better for the distribution of resources by specifically focusing on the areas predicted to be at high risk.

Smartphones to improve health workers performance and rational drug use for management of childhood illnesses in low resource settings.

Author(s) Clotilde Rambaud-Althaus1, Amani Shao2, Ndeniria Swai3, Seneca Perri 4, Marc Mitchell 5, Judith Kahama-Maro6, Valerie D'acremont7, Blaise Genton8
Affiliation(s) 1Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Geneva, Switzerland, 2Amani Research Center, National Institute of Medical Research, Dar es Salaam, Tanzania, 3City Medical Office of Health, Dar es Salaam City council, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 4Nursing informatics, University of Utah, Salt Lake city, USA, Salt Lake City, United States, 5Department of Global Health and Population, Harvard School of Public Health, Boston, United States, 6City Medical Office of Health, Dar es Salaam City council, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 7Infectious Diseases Service and Department of Ambulatory care and Community Medicine, University Hospital, Lausanne, Switzerland, Lausanne, Switzerland, 8Epidemiology and Public Health department, Swiss Tropical and Public Health department, Lausanne, Switzerland
Country - ies of focus Tanzania
Relevant to the conference tracks Innovation and Technologies
Summary In low resource settings, where childhood mortality is high, health workers (HWs)’ compliance to guidelines is essential to improve management of childhood illness. We developed paper and electronic versions of an algorithm for the management of childhood illness (ALMANACH) combining clinical elements with rapid tests for malaria and urinary infection. We assessed HWs’ compliance to guidelines when using paper versus electronic ALMANACH. The electronic clinical decision supports improved HWs performance in terms of symptoms assessment and rational use of drugs. However, it did not improve the accuracy of bacterial diseases diagnoses, which is essential to ensure quality of child care.
Background In low resource settings, where qualified health workers (HWs) are scarce and childhood mortality due to infectious diseases is high, the overuse of antimicrobial drugs is fastening the emergence of drug resistance. HWs’ compliance to evidence-based guidelines has the potential to improve the rational use of drugs and ensure quality of health care for children. Available new mobile technology, through smartphones and tablets, offers new perspectives in the delivery of evidence-based clinical guidelines to remote ambulatory health workers.
Objectives Our aim was to assess whether the use of smartphones to deliver a clinical ALgorithm for the MANAgement of CHildhood illnesses (ALMANACH) improves health workers diagnostic performance and rational use of drugs through a better compliance to the clinical chart.
Methodology ALMANACH, a decision chart combining clinical elements with a rapid test for malaria and a urine dipstick, was developed both on paper and electronic version. Nine Primary Health Care Facilities (PHCF) in Dar es Salaam, Tanzania (United Republic of), were randomized into 3 arms. Three PHCF were allocated an intervention using Paper ALMANACH, 3 other PHCF used Smartphone ALMANACH, the remaining 3 followed routine practice. The intervention, in Paper and Smartphone arms, consisted in a 2 days training on ALMANACH for all HWs attending to children below 5 years of age in outpatient departments (OPDs). The training was followed for each HW by one day of on-site supervision, and monthly supervision visits to the PHCF. Smartphones running ALMANACH algorithm were provided to the PHCF in the phone arm. The same ALMANACH algorithm printed as a paper booklet was provided to the PHCF in the Paper arm. Control PHCF did not receive any algorithm nor training or supervision and thus managed patients as usual. From September to November 2011, we conducted a cross sectional consultation process observational survey in the 9 PHCFs. Children aged 2-59 months, coming for the first visit for an acute medical ailment, were enrolled. All consultations were observed by a surveyor who collected data on a standardized form. An expert re-examined each child to establish the ‘gold standard’ assessment and treatments needed. We compared HWs’ performance between the 3 arms using indicators of child’s assessment, and appropriateness of diagnosis and treatment as outcome variables. Indicators (proportions) were compared using the Fischer’s exact test and 95% confidence interval (95%CI). The expert consultation was the reference.
Results A total of 504 children were enrolled. The mean age was 19.7 months (interquartile range 8-29) and 261 (52%) were males. The most frequent symptoms at presentation were: fever (71%), cough (66%), diarrhoea (20%) and skin problems (8%). The use of smartphones was associated with better child assessment indicators. The proportion of children checked for 3 dangers signs (unable to drink, vomits everything, and history of convulsion) was 74% (95%CI, 67-81%) when using smartphones, 41% (34-49%) when using paper ALMANACH and only 3% (0.4-6%) in the control arm. The proportion of children checked for main symptoms (fever, cough, and diarrhoea) was 99% (98-100%) when using smartphones, 75% (68-81%) when using paper ALMANACH and 77% (71-84%) in controls. The proportion of children with reported fever tested for malaria was 72% (63-80%), 92% (77-90%), and 84% (77-90%) in smartphones, paper and control arm respectively. The proportions of children with reported fever and cough who had their respiratory rate measured (for diagnose pneumonia) were 38% (27-49%), 53% (42-65%) and 3% (0-7%) in smartphones, paper and control arm respectively. With regards to diagnostic appropriateness, the proportion of expert-validated viral diseases identified by HWs (diagnostic sensitivity) was 74% (65-82%) with smartphones, 35% (26-44%) with paper and 45% (37-56%) in control arm. On the other hand, identification of expert-validated bacterial diseases (pneumonia and dysentery clinically diagnosed, and urinary tract infection using dipstick urinalysis) remained low in all 3 arms, with the proportion of validated bacterial infections identified by HWs at 41% (21-61%), 33% (20-65%), and 36% (15-58%) respectively. Nevertheless, the use of ALMANACH was associated with an important decrease in unnecessary antibiotic prescriptions. The proportion of children not needing antibiotics who were still prescribed antibiotics by HWs was: 20% (13-27%) in the smartphone arm, 25% (19-33%) in the paper arm and 66% (58-74%) in controls. Seven among 12 children in the paper arm and 14 among 26 children in the phone arm who needed antibiotics according to the expert, were not prescribed antibiotics by the HW. All these 21 cases were diagnosed as non-severe pneumonia by the expert, based on a respiratory rate above 50 breaths/min. For 10 (1 in paper, 9 in phone arm) of these patients, HWs did not measure the respiratory rate and did not consider pneumonia diagnosis. In the remaining 11 patients, HWs’ respiratory rate measures were below the threshold of 50 breaths/min. This difference could be due to inaccurate measurement by the HW or alternatively, to natural fluctuation of the respiratory rate between the two assessments.
Conclusion The use of ALMANACH compared to control arm was associated with better child’s assessment and considerable reduction of unnecessary antibiotic prescription. The use of smartphones running ALMANACH software versus the use of the paper ALMANACH was associated with better symptoms assessment and better identification of viral diseases. However, the discriminative clinical and lab tests available (i.e. respiratory rate for pneumonia, and malaria test) remained underutilized after our intervention, with no significant difference between smartphones and paper arm. This resulted in missed antibiotic prescription for about half of the children in need of it according to ALMANACH, both in the smartphone and the paper arm. The use of smartphones, a powerful tool to guide HWs during the consultation, is not enough to convince them to use the key clinical and lab tests in all children. Devices that would directly measure the respiratory rate, or point-of-care tests identifying pneumonia or severe disease, are highly desirable. A supportive working environment, with iterative supervision is necessary to ensure the rational use of antimicrobials by HWs.

Improving Elderly Autonomy Through Serious Gaming and Social Networking.

Author(s) Emilie Pasche1, Rolf Wipfli2, Christian Lovis3
Affiliation(s) 1Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 2Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 3Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Innovation and Technologies
Summary In fifteen years, the number of octogenarians will have increased by 80%. With the ageing of the population, chronic diseases are expected to double by 2050. Healthcare systems may collapse under the weight of the demand. In this context, the MobilityMotivator project aims to provide elderly people with a tool to help them age well by improving their mobility and preventing social isolation. This project follows a four-step plan: a specification phase, a prototype development phase, an evaluation phase and a dissemination phase. The conclusion of this project will enable us to determine the impact of such an approach on the mobility of elderly people and the socio-economic impact.
What challenges does your project address and why is it of importance? Only a minority of elderly people perform a sufficient amount of physical exercises. A study performed in England reported that only 17% of men and 13% of women aged 65-74 reach the recommended levels of physical activity. There are many reasons why elderly do not feel they can or should engage in physical activity (e.g. fear of injury, physical limitations, etc.) which leads to a lack of motivation. The consequences of this lack of activity directly results in the decrease of the quality of life of elderly people, with the increased risk of developing chronic diseases (coronary heart diseases, diabetes, etc.) and increased social isolation. Moreover, because of the growing proportion of older adults, this represents an increasing public health problem.
The challenge of this project is to motivate elderly people to remain engaged in physical activities so that they stay connected with their peers. This challenge is of major importance to both the individuals and the society. For the individual, it is essential to age well in order to have a satisfactory quality of life and autonomy. For the society, active ageing will reduce the health costs and also ensure that the healthcare system is able to manage the demand.
How have you addressed these challenges? Do you see a solution? The MobilityMotivator project proposes an approach based on the development of a serious gaming environment to motivate elderly to remain involved in physical activity and social interaction. The approach proposes two modes: a telemonitoring mode and a gaming mode.
The telemonitoring mode is dedicated to the healthcare provider and enables them to supervise and encourage their patients to undergo physical activities, but also to remain active and engaged within the urban environment. The patient performs exercise at home in front of his television and the healthcare provider is provided with monitoring mechanisms to assess cognitive and physical performances of his patient through the Mobility Motivator platform. It also enables the healthcare provider to define the level of challenges for their patient according to the patient's abilities.
The gaming mode is dedicated to elderly people. The game relies on two elderly people playing together: the outdoor player and the indoor player. Initially, both players get in touch through the platform and start a game. The choice of challenges is based on an intelligent engine that customises the game according to the individual’s assessment for mobility and cognitive capacities. The outdoor player, who is provided with a smartphone, faces a mission such as making his way to the museum in the centre of the town. He moves through the game and performs tasks associated with the mission. At some points, the outdoor player interacts with the indoor player, thus receiving feedback and encouragement. During the time, the indoor player is challenged with a cognitive enigma, such as solving simple orientation problems in a given time, or with indoor physical activities such as chair exercises. The end of the game will be achieved when players reach the final destination. The players can repeat the game process at a later date by switching roles. Over time, the game builds a record of progress, which can be analysed by the healthcare providers when evaluating each patient’s mobility and cognitive abilities.
Although health e-games generally provide health literacy, physical fitness, cognitive fitness, skills development and condition management, these are mainly designed for mainstream consumers rather than the over 65 not familiar with technology like the MobilityMotivator. In addition, no other health e-game incorporates telemonitoring functionalities to enable feedback provided by healthcare providers.
How do you know whether you have made a difference? The development of the solution will be based on a rigorous assessment and monitoring of user needs and interests and will be tested through three user representative organisations in three European countries.
The impact evaluation in real living and working environments will aim to assess the usability of the MobilityMotivator environment under real living and working conditions, using key indicators applicable to indoor and outdoor situations. This evaluation will also enable to determine the impact on mobility, autonomy and socio-economic parameters in comparison to a parallel control group experiencing conventional living and working conditions. A number of qualitative and quantitative indicators for success will be identified. Methods for collecting these indicators in an unbiased way will be defined. Data collection will be designed and planned with the support of statistics experts in the design and analysis of clinical trials.
Have you or the project mobilized others and if so, who, why and how? The project is a European research project which is composed of a consortium of nine partners distributed in six countries: Laboratory of Engineering Systems of Versailles (France), Institute für Arbeit & Technik (Germany), Audemat (France), Inventya (England), E-Seniors (France), University Hospitals of Geneva (Switzerland), German Red Cross (Germany), Studio 345 (Luxemburg) and La Mosca (Belgium). The consortium has been designed with careful consideration to the following key requisites. First, the portfolio of complementary skills necessary to ensure project objectives is met. Second, the consortium comprises a balance between industrial SMEs, research community, user involvement and market expertise. Finally, geographical spread aims to facilitate initial establishment in three European countries (Switzerland, France and Germany) as a foundation for future growth and expansion.
When your donor funding runs out how will your idea continue to live? The market for MobilityMotivator has great potential since it is still largely untapped. A study conducted by Empirica found that a mixed market for technologies, which promote active ageing and other telecare related ICT-products, is emerging. Older people from some countries are starting to privately purchase such products and services in order to age well. Healthcare providers may also be interested to improve the quality of care and supervision provided. Moreover, a modest investment in devices that encourage mobility that could improve the ageing process has the potential to save several billions per year in Europe. Dissemination activities need to be focused on all these actors to convince them of the value of having access to the MobilityMotivator environment. There are signs that, with sufficient support, the market for technology for the elderly can be accessed.
European-wide exploitability of the MobilityMotivator is considered from the very start of the project. The consortium partners plan to launch a Joint Venture in order to implement exploitation strategies and business plans following project completion. This is expected to be achieved within the 2 years of project completion. The potential return on investment will be further investigated following the development of the business model in the research phase.

Patient Age, Sex, Education and Income level determine Mobile Phone use in HIV Care.

Author(s) Naieya Madhvani1, Michele Santacatterina2, Ziad El-Khatib3.
Affiliation(s) 1Project completed at IHCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Currently Leicester, UK. Previously Stockholm, Sweden., United Kingdom, 2Unit of Biostatistics, Department of Environmental Medicine., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Stockholm, Sweden., Sweden, 3HCAR Department of Public Health Science., Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden., Ottawa, Canada., Canada.
Country - ies of focus South Africa
Relevant to the conference tracks Innovation and Technologies
Summary Despite years of goal making and action taking, Human Immunodeficiency Virus (HIV) remains a major global health issue. Challenges include retaining patients in care and optimising adherence to Anti-retroviral Therapy (ART). Mobile phones are one possible solution to these challenges. The main aim of our study was to identify patient demographic groups least likely to use mobile phones as reminder tools in HIV care.
Background During the last thirty years the number of HIV cases in South Africa has dramatically increased. In the 2012 World AIDS Day Report it was reported that 5.6 million people were living with HIV in South Africa – the highest absolute number of HIV cases for any country globally. Despite these bleak statistics, South Africa has one of the highest ART coverage levels in low- and middle-income countries. This underlines the relative success of ART roll out in South Africa.Even with this relative success there are a number of challenges associated with HIV care both worldwide and within South Africa. These include: 1) retaining patients in care and 2) optimising adherence to ART. One possible solution is using mobile phones as reminder tools. Importantly mobile phone use relative to other electronic devices is high in South Africa. According to a study of consumer behaviour by, there are a reported 29 million people mobile phones users relative to a mere 5 million landline users in South Africa. This is a strong reason for choosing South Africa as the setting for fulfilling the general aim of this study.
Objectives The overarching aim of this study was to explore and answer the following question: Which patient demographic groups are least likely to use mobile phones as reminder tools in HIV care, in Soweto, South Africa? Specific objectives included 1) to identify the types of reminders used and the frequency of use of such reminders 2) to assess whether using more reminders improves i) retention in care and ii) adherence to ART, 3) to identify patient demographic groups least likely to use mobile phones as reminders for i) attending clinic appointments relating to appointment reminders (ARs) and ii) taking medication on time relating to medication reminders (MRs).
Methodology The data for this study comes from a cross-sectional study carried out at the Chris Hani Baragwanath Hospital, Soweto, in the outskirts of Johannesburg, South Africa, during March to September 2008. The study was performed at two clinics, one, a Non-Governmental Organisation (NGO) clinic and another a public health clinic. Patients were recruited through posters. An English interview questionnaire was developed and translated into Sesotho and isiZulu. The questionnaire was first piloted and then edited. The final version included 59 questions (210 items). Some questions asked for basic demographic information whilst other questions focused on specific areas of HIV care such as: failure to attend clinic appointments, reminders for attending appointments, ART adherence over the last weekend and reminders for taking medication. Information was collected on demographic characteristics, reminders used for attending clinic appointments, failing to attend appointments, reminders for taking medication and failing to take medication. Firstly, basic descriptive analysis was performed to characterise the study population and obtain frequencies for i) ARs and ii) MRs. Secondly, logistic regression analysis was performed to identify the relationship between a number of variables and the use of ARs and MRs.
Results With regards to ARs: the majority of patients reported using a clinic register card with the appointment date written on it (N=543; 61.5%). Other popular reminder tools were diary/appointment book (N=192; 21.7%) and memory (N=183; 20.7%). A relatively small percentage reported using a mobile phone (N=93; 10.5%) and a similar percentage said they used a close friend/relative (N=86; 9.7%). Few patients reported using a partner (N=36; 4.1%), friend at work (N=2; 0.2%) or other reminder device (N=14; 1.6%). Patient groups significantly associated with being less likely to use mobile phones, as clinic ARs, in the final model were: a) patients 45 years or older (P=0.001), b) women (P=0.015) and c) patients with only primary or no schooling level. (P=0.034).With regards to MRs: the most popular reminder tool was the mobile phone (N=431; 48.8%). A similar percentage of patients reported relying on their memory (N=429; 48.6%). Approximately one fifth of patients used a close friend/relative (N=173; 19.6%) or other reminder device (N=176; 19.9%). A relatively small number of participants used their partner to remember to take medication (N=68; 7.7%). Less than one percent of patients reported using a pill box (N=7; 0.8%), a diary/appointment book (N=5; 0.6%) or a friend at work (N=6; 0.7%).
Conclusion Our study found that people infected with HIV in Soweto, South Africa use a variety of reminder tools in HIV care and that specific demographic groups (those of older age, women, with lower educational attainment and lower income) were less likely to use mobile phones as reminders in HIV care.With the results from this study we highlighted a number of further questions and provided various study suggestions. As per the World Health Organizations (WHO) report on Mobile Health (mHealth) these can be combined into a number of recommendations for the advancement of mHealth in South Africa.1) We suggest exploring further and gaining knowledge on why HIV patients don’t use mobile phones in Soweto, South Africa and then second to investigate additional patient variables associated with using/not using mobile phones.2) Given the high penetration of mobile phones within South Africa and the finding that almost 50% of patients in our study used mobile phones as reminder tools for taking medication, there is a strong argument for making mHealth a bigger priority within South Africa.3) There is still much to be researched but the most conclusive evidence will come from larger scale studies that incorporate a larger sample of the general population and which focus on cost-effectiveness analysis.

4) By combining evidence-based knowledge regarding the clinical and cost-effectiveness of mHealth in HIV care together with prioritising mHealth on the South African health agenda we hope and anticipate that policy makers will have enough to formally prioritise mHealth on the national health agenda and specifically develop mHealth focussed policy.

CBK-learning: new technologies for the health education of prospective and new parents.

Author(s) Christian Oberlé1, Stéphanie Blaise2,
Affiliation(s) 1Management Department, Clinique Bohler, Luxembourg, Luxembourg, 2Management Department, Clinique Bohler, Luxembourg, Luxembourg, 3
Country - ies of focus Belgium,Germany,Luxembourg,Mali
Relevant to the conference tracks Innovation and Technologies
Summary Health education and coaching represents 75% of the support given to birthing mothers during their hospital stays. The important need for information and support before and after the birth of their child convinced Clinique Bohler to invest in the development of an e-Learning platform, adapted to the lifestyles of young parents. Cbk-learning is an innovative concept in the field of women’s health education and prevention. Incorporating new multimedia technologies into health education can facilitate access to quality information tailored to the needs of the patients and help maintain remote contact with them. It is an educational tool that has a great resource sharing and co-development potential.
What challenges does your project address and why is it of importance? 1.Establish early contact with the patient base.
In Luxembourg, the future mother has the first contact with the staff of the Clinic around the 6th month of pregnancy when attending prenatal workshops. To better inform and support prospective parents throughout the pre natal period we need to make contact with them at an earlier stage.
2.Develop communication channels and innovative training
Patients are increasingly turning to the internet to find answers to their questions about health. It is important to be kept up with our patients’ lifestyles and listen to their evolving expectations.
3.Be accessible to current customers whatever their geographic distance to the Clinic
The distance between home/work and the maternity centre can be a significant barrier for the future mother in attending prenatal workshops.
4.Provide consistent information and quality education before, throughout and after the patient's hospital stay.
Health information found on the internet is not necessarily reliable. As a hospital we have the expertise to provide reliable information to future parents.
5.Anticipate patient questions, needs and concerns
The birth of a child is a major event: it requires special attention because prospective and new parents are particularly sensitive and they need responses and attention.
How have you addressed these challenges? Do you see a solution? Solutions according to challenges:1. Establish early contact with the patient base.
In the early stages of the pregnancy patients are invited by the medical secretaries to preregister for cbk-learning. It is a very simple process.2. Develop communication channels and innovative training.
The use of new multimedia technologies can enhance and facilitate access to quality information tailored to the specific needs of the patient base and help maintain remote contact with them.It is a new concept for educating and supporting pregnant women and facilitates access to information (remote exchanges).

The platform now embeds social media networks as well (interactive sessions accessible to facebook fans, possibility to share contents). It is very much in sync with the habits of younger generations who need to be connected to a community based on their particular situation or interests.

3. Be accessible to current customers whatever their geographic distance to the Clinic is.
E-learning is a solution to create the contact with these patients and offer them access to essential information and even remote access to prenatal workshops.

4. Provide consistent information and quality education before, throughout and after the patient's hospital stay.
The patients’ need for consistent and reliable information was the source of the creation of the e-learning website. The content of the platform is validated by a Committee composed of midwives, staff, management, social adviser, nurses, pediatrics, and gynaecologists.

5. Anticipate patients questions, needs and concerns.
The e-learning site is built around the main questions and concerns expressed by the parents.
We gathered an inventory of the most frequently asked questions in prenatal classes and consults, analysed them and relied on evidence-based nursing to build the contents of the e-learning website.

The e-Learning platform developed by Clinique Bohler is:

• A unique platform for preventive healthcare and health education of women and an effective support tool for future parents through new multimedia technologies.
• A library of learning tools (educational videos, quiz, animations) in gynaecology and obstetrics.
• An internet-based broadcasting tool of live interactive sessions given by the nursing staff which allows patients to actively participate in the classes from home or during their hospital stay.
• An innovative way to ensure ongoing consistent training for the nursing staff.

How do you know whether you have made a difference? The key figures for 2012, be it the number of visits, the average time spent on the site per visitor, or the geographical origin of the visits, illustrate the relevance of this e-learning initiative
• Nearly half of the patients who gave birth at the Clinic Bohler in 2012 (2680 births) were registered on the e-learning site. The number of registration increased in 2013
• The presence of patients online for the interactive classes is constantly increasing, as is the number of patients physically present in the rooms.
• A visitor remains on average about 7 minutes on the website, which is way above the average of traditional websites.
• Other key figures (2012): 7048 Views, 3483 Unique Visitors, 47721 Page viewsThe qualitative feedback we get from our patients and the more targeted questions they raise when they come to the Clinic for the birth of their child also go a long way to validate the benefits in the area of health education of this new approach we’ve developed with our e-learning solution.
Have you or the project mobilized others and if so, who, why and how? We have implemented a series of targeted partnerships to ensure the viability, the sustainability and the successful deployment of the platform.
• Educational partnership with a Nursing school
The Clinic has achieved a close partnership with Henallux(midwifery/nursing School) for the development of pedagogical tools.The school can use cbk-learning platform for its health education courses and in return, students and teachers from the school participate in the development of the cbk-learning contents.
• Partnerships with selected clinics/hospitals
The development of professional quality content for the website is consuming both financially and in terms of human resources for a single hospital. Sharing of complementary knowledge and resources with other clinics seemed the best way to ensure the future of the platform.The idea was also to choose partners who could help making the platform multilingual, and especially in the languages spoken in Luxembourg (German, Portuguese, English).
Current status of partnerships:
• Germany is already covered by a partnership with Frauenklinik Dr Geisenhofer (Munich).
• Portugal will soon be covered with a partnership with a University Hospital from Coimbra.
• Belgium is already covered with a partnership with Clinique Saint-Vincent.
• We hope to achieve a partnership that will cover the needs of English speaking patients.
Another objective in engaging in partnerships with other hospitals would be to open the opportunity for the platform to broaden its scope to areas other than obstetrics.
• Partnerships for Corporate Social Responsibility
CBK-learning is an educational tool that can potentially be deployed in areas of the world where prenatal care and women’s health education are major public health issues. The idea is to replicate a concept that was already successfully tested in Europe, while adapting it to local contexts, needs and means as an addition to local programs. This can be done with partners with a good local knowledge and a solid regional implementation. From that perspective, we entered in a joint-project in Mali with the Fondation Raoul Follereau. The objectives are to capitalize on the contents of the existing e-learning platform to create videos and technical recommendations on various formats that local healthcare professionals can use to reinforce the training of local health personnel in the fields of obstetrics and early childhood, and increase the number of pregnant women attending prenatal consults
When your donor funding runs out how will your idea continue to live? Our project will continue to live through:- Partnerships based on co-creating contents and resources and sharing the cost of maintaining and developing the platform
- Generating revenues by developing a client-base of hospitals and healthcare professionals who wish to give their patients access to the e-learning platform and will pay a registration fee to the platform, thus financing in part the development of the new contents and the operating costs.
- European or country specific subsidies are likely to be allowed to this initiative, as the platform contributes to public health objectives and promotes European collaboration in the health sector.

mTB by Front Line Workers in a Tribal District in India: A Pilot Study

Author(s) Archana Trivedi1, Sarabjit Chadha2, Nevin Wilson3, Sunita Prasad4, Sanjay Kumar5
Affiliation(s) 1Public Health, USEA, The Union, New Delhi, India, 2Health, Communicable Diseases, USEA, The Union, New Delhi, India, 3Health Communicable and Non Communicable Diseases, USEA The Union, New Delhi, India, 4CSR, Lilly Foundation Grant in association with Lilly MDR TB partnership, New Delhi, India, 5IT, USEA, The Union, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Innovation and Technologies
Summary The Union through a community engagement process has mapped and trained Rural Health Care providers who are “first point of contact” for marginalized and vulnerable population. The trainings have contributed to imparting knowledge about TB and referrals of TB symptomatics to the National TB Control Programme. A paper based referral mechanism is established to capture data on quality of referrals made. However, providers often lack information about referred TB symptomatics – results and follow-up. Through the mobile phone application, this project is demonstrating the use of mobile technology in establishing a mechanism to impart knowledge and continued engagement with TB symptomatics.
What challenges does your project address and why is it of importance? Background and Challenges to implementation: Front Line Workers/Rural Health Care Providers (RHCPs) are most often the first point of contact for curative services in many villages, especially in tribal and remote geographic areas. A paper based mechanism is used to capture the data on referrals made including the results of their sputum examination and the management of those diagnosed with TB.However, Front Line Workers including RHCP’s and Lab Technicians (LTs) often lack information about referred cases with chest symptoms. Validating the referrals at designated microscopic centers is resource intensive, time consuming and difficult. It is also difficult to attribute the contributions made by FLWs towards strengthening National TB Control Programme.
How have you addressed these challenges? Do you see a solution? The intervention being implemented to address the challenges is ‘CommCare’ (mobile platform), an easily customizable mobile platform that tracks the referred cases, supports FLWs and creates a central database on a real-time basis.The CommCare application is being piloted in three blocks namely Torpa, Murhu and Khunti of Khunti, a tribal district in Jharkhand, India covering a population of 2,55,372 (80% district population). Two ComCare applications have been developed. One application is being used by RHCP and NGO supervisor, and one by LTs.FLWs are provided with 30 Lava Android phones. ComCare aids FLWs with guidance on key counselling points. Each counselling point is reinforced by images and audio clips that FLW uses to engage their clients. Messages are displayed regardless of the result of sputum examination and are focused on “Shared Air, Safe Air.”
How do you know whether you have made a difference? Results and Lessons Learnt: ComCare is a management system that assists in the follow up of referred chest symptoms by FLWs for the purpose of efficient diagnosis and treatment of tuberculosis. It reduces the delay in communication of the test results and saves resources by reducing the number of visits of the FLWs to the diagnostic centres. It helps to assess the contribution of FLWs in total chest symptoms examined and TB cases diagnosed. This application provides data lost follow up cases and creates a real-time central database which in turn helps with the retrieval of cases.In three months ninety symptomatics have been referred by using this application.  From these, 17 were diagnosed as  sputum positive TB and 6 sputum negative TB. All of these 23 diagnosed Tuberculosis patients are put on DOTS and are regularly being counselled through the mobile application. The outcome of patients who are being regularly counselled will be assessed upon completion of treatment.
Have you or the project mobilized others and if so, who, why and how? Mobilisation of other stake holders: The Project has explored possibilities for sustainability and scaling up of the use of mobile technology to promote TB care and control through collaboration under the World Bank Project by the matching of 25 additional mobiles in Jharkhand (tribal state, Khunti).These mobiles have been initiated to be used in one of the Global fund Round 9 project districts in Jharkhand. The project has moved beyond pilot to scale it up and illustrates the impact of implementing innovative technologies to address the challenge of tracking referred symptomatics by front line workers.Due to the positive impact of intervention, procurement of 50 additional mobiles has occurred and expansion is being initiated in one more district of Ghazipur in Uttar Pradesh, with additional mobiles at Khunti in Jharkhand. In this implementation mobiles are given to LTs of 3 respective districts who work in close collaboration with front line workers. This implementation is being appreciated by RNTCP officials.
When your donor funding runs out how will your idea continue to live? Potential framework for sustainability when donor funding runs out: Implementation of pilot project on use of CommCare application to track TB symptomatics is initiated in a tribal district and POC grant from Dimagi (USAID fund) for 1 year and expansion has been initiated in Ghazipur (UP), Khunti (Jharkhand) and one other tribal district in Jharkhand.
Scaling up the use of the mobile application is being anticipated well in advance so that project is not restricted to a pilot study only.Proposed Partners will be Identified partners under the implementation of the Axshya Project (Global Fund Round 9) in 300 districts and Dimagi representatives.
Roles & ResponsibilitiesSelection of front line workers for the use of mobile technology application and selection of geographical areas for implementation of mobile application can be done through the Implementing NGO partners. Training of front line workers and NGO Supervisors on the use of CommCare application can be done through projects that train these front line workers by USEA, The Union. Follow up implementation of these applications is carried out by NGO supervisors of identified NGOs in implementing districts.Who Pays? Recurring costs of implementation will be carried out by linking NGOs with districts upon the take up of the NGO PP RNTCP schemes.

We intend to develop trust of the government health system and the community as to the benefits of the application and slowly encourage government investment in the project.

ICT Model delivers integrated Primary Healthcare and Allied Services in Developing Countries? Evidence from India

Author(s) Atanu Garai1.
Affiliation(s) 1Odisha Modernising Economy, Governance, and Administration (OMEGA), IPE Global, Bhubaneswar, India.
Country - ies of focus Global, India
Relevant to the conference tracks Innovation and Technologies
Summary Various functional units of a health system depend on data and communication generated by its peer units and stakeholders for effective planning, implementing, and assessing its own functions. Currently, functional units maintain aggregated MIS data that does not provide the peer units and stakeholders any option to plan, deliver, and assess requirements, access, and usage of health services for individual beneficiaries. Effectiveness of planning, delivery, and assessment of health system functions depends on data and communication from other units. With practical examples from India, this paper designs an ICT model for better data communication by healthcare systems in order to improve outcomes.
Background Providers remain handicapped in delivering patient (beneficiary)-centric care due to the fragmentation of their functional operations. In primary and secondary care in promotional, preventive, curative, and rehabilitate health areas, providers and beneficiaries perform and access eight functions – i) planning, monitoring, and supervision, ii) service delivery (including medical and clinical aspects), iii) information and communication, iv) human resources management, v) financial management, vi) procurement and supply chain management, vii) asset and facility management, and viii) transport services management (Figure 1: Eight health system functions). Different units of health providers, sometimes different organizations, perform these functions with limited or no coordination among themselves. As a result, access and use of healthcare often remains unavailable due to actions by different agencies separated by time and space. Aggregated MIS data does not provide the peer units and stakeholders any option to plan, deliver, and assess requirements, access, and usage of health services for individual beneficiaries. This drawback can be overcome by using data on individual beneficiaries and the data can be used by all peer units for undertaking various functions.
Objectives WHO (2000) in its report “World Health Report 2000: Health systems: Improving performance” demonstrated the linkages of functional services with health system outputs and outcomes (Figure 2: Relations between functions and objectives of a health system). This paper identifies eight different functions that providers and beneficiaries access, perform, or use in various promotional, preventive, curative, and rehabilitative health areas in Indian health system. Discussions with select providers show that their organizational units have been performing their allocated functions with limited or no coordination. Besides, they do not get or use data from their peer units in planning and performing their activities. Therefore, providers disregards need, ability, and health status of the beneficiaries in the delivery of those services. This paper explores the linkages and impact across these eight functions and their sub-activities to intended health system outcomes.To improve access, delivery, and usage of health services, different units, organizations, and stakeholders shall plan, manage, and evaluate their respective functions by communicating data on beneficiaries. ICTs can effectively record, retrieve, and communicate data. This paper explores how ICT helps providers in primary and secondary care settings in India are using in these eight functions. This paper uses the functional relationships to explore the role of ICTs providing responsible functional units coordinate with other units in promoting coordination. It is argued that coordination among different functional units leads to integrated service access and delivery to achieve patient-centric integrated service delivery.
This paper has following objectives:
a) To establish causal linkages of different health system functions with outcomes, showing the dependency of different functional units within providers in promoting access and usage of health services.
b) To assess the status of limited coordination among peer units in planning, performing, and evaluating health services and its suboptimal impact on the health outcomes.
c) To assess the role and effectiveness of ICTs in allowing different units to plan, perform, and evaluate their functions to provide beneficiaries integrated and planned access to health services.
d) To evolve a patient-centric ICT model which allows the multiple units and stakeholders of providers leverage data and communication.
Methodology A literature review provides data to support analysis. The literature review uses systematic review method to search major databases including Academic Search Complete, Econlit, Google Scholar, MEDLINE, PubMED, SocINDEX, among others. Then, we screen the title and abstracts to examine their relevance for the key questions. It is likely that most literature shall use qualitative methods to examine the questions of linkages of health system functions and outcomes.
On the issue of the effect of limited coordination on the effectiveness of the functions carried out by different organizational units and stakeholders, we shall conduct interviews with select practitioners in the health sector in India.There is a growing body of literature examining the effectiveness of ICTs in various health system functions. This paper only shows the applicability and effectiveness of ICTs for specific functions. We shall use case studies showing projects implemented in India or other developing countries to show the applicability and relevance.
We shall analyze the data gathered through literature review and interviews to extrapolate key findings. Based on those findings, we shall develop a model which demonstrates the use of ICTs to generate useful data and communication for planning, management, and assessment of various health system functions.
Results This paper expects to show that the ICT applications can be effective in improving eight health system functions: i) planning, monitoring, and supervision, ii) service delivery (including medical and clinical aspects), iii) information and communication, iv) human resources management, v) financial management, vi) procurement and supply chain management, vii) asset and facility management, and viii) transport services management (Figure 1: Eight health system functions).It also shows that the data and communications from ICT applications used for planning, monitoring, and supervision can  improve the seven functions. Similarly, data and communications from service delivery can help program managers improve their monitoring and supervision.Until now, the responsibility of information and communication was delegated to mass and media organizations. The emergence of ICTs among populations has now enabled the service providers to communicate directly with their beneficiaries. Besides, data and communication from applications managing human, finances, and transport services can help improving various services.
Conclusion This paper helps the stakeholders underline the usage of data and communication by multiple functional units generated by their peer units. For generating data and communication, functional units shall use appropriate ICTs. This discussion on appropriate ICTs and their role in providing data and communication for various functional units plan, manage, and implement actions can help health providers implement a patient-centric integrated delivery.

Alternative Approaches to New Drug Development: Two R&D Initiatives

Author(s): Philippe Desjeux1, Bernard Pécoul2
Affiliation(s): 1Senior Programme Officer for Disease Control, iOWH, San Francisco, CA, USA, 2Executive Director, Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
Summary (max 100 words): Philippe Desjeux: The illnesses of invisible people usually stay invisible. This statement is reflective of the limited attempts to develop new treatment regimens for neglected diseases. Most of these diseases are preventable or curable, but often strike poor and marginalized people living in remote rural areas. Development of effective, safe and affordable drugs for neglected diseases is an urgent need. Many of the available drugs are not adequate: they are either toxic, difficult to administer or too expensive. Therefore, investment in drug research and development for neglected diseases is crucial to bridge the gap between the pharmaceutical R&D model and the unique requirements of the global health field, where the traditional market system does not work. Meeting the challenge: The Institute for OneWorld Health (iOWH) is the first non-profit pharmaceutical company in the USA, formed to address the 10/90 gap in health R&D. Our mission is to develop safe, effective and affordable new medicines for people with infectious diseases in the developing world. OneWorld Health’s core competencies lie in pharmaceutical product development. Our in-house teams identify development leads through partnerships with industry and universities. Together, iOWH works to optimize existing drug candidates, complete preclinical and clinical investigation needs, secure quality manufacturing of developed products, and obtain the necessary regulatory approvals to bring the product to the beneficiaries. Concurrently, iOWH collaborates to devise product delivery and access strategies with relevant stakeholders, which include governments, donors, and international NGOs. These Public-Private Partnerships (PPPs) allow for a more rapid development of new drugs by utilizing complementary skills and resources. iOWH’s current pipeline includes programmes for visceral leishmaniasis (VL), malaria, and diarrheal disease. Paromomycin, for the treatment of VL, is currently the most advanced pharmaceutical product for iOWH. After the completion of a Phase III clinical trial in Bihar, India, for paromomycin, iOWH has submitted the dossier for regulatory approval in India. iOWH’s product selection criteria is designed to meet the needs of the poor in the developing world. In addition to customary selection criteria such as scientific merit, probability of success, clinical and regulatory developmental path, iOWH examines the unmet medical needs in the developing world, cost-of-goods, and mechanisms of delivery, including the endemic country’s infrastructure. These criteria allow us to devise products that will be both appropriate for communities with high disease burden and affordable and accessible to the population in a manner which is sustainable. Conclusions: iOWH strives to provide a flexible and innovative vehicle to engage both the pharmaceutical and biotech industries, as well as public health organizations in global health product development. Through partnerships and collaborations, by adhering to the highest ethical standards for clinical research, and by utilizing the scientific and manufacturing capacity of the developing world, OneWorld Health can deliver affordable and effective new medicines where they are needed most.Bernard Pécoul: The majority world shoulders a disproportionate burden of disease and has few drugs with which to respond to this challenge. In 2005, Africa, Asia (excluding China)- Pacific, and Latin America, which housed 63 per cent of the world?s population, had a mere 11.7 per cent share of the world's $602 billion pharmaceutical market. This stark disparity is echoed in the dearth of research funding dedicated to the diseases prevalent in developing regions. Over the past 30 years, only 21 of the 1,556 new chemical entities marketed between 1975 and 2004 were for tropical diseases and tuberculosis. Millions continue to suffer from diseases such as tuberculosis, malaria, leishmaniasis, sleeping sickness, and Chagas disease. Regrettably, these diseases target impoverished populations with immune systems already weakened by hunger and other diseases. If patients are to have any hope of survival they urgently need new, more effective treatments for these diseases, as the few available drugs are compromised by poor efficacy, toxicity, long courses of treatment, parenteral administration and resistance to the parasite.
Meeting challenges: The Drugs for Neglected Diseases Initiative (DNDi), a not-for-profit drug R&D initiative, is seeking to research and develop new drugs for these neglected diseases. Existing treatments for these diseases are often inadequate and ineffective and patients need new medicines urgently. Founded by a group of 5 renowned medical research organizations including the Indian Council for Medical Research, the Oswaldo Cruz Foundation from Brazil, the Kenya Medical Research Institute, the Ministry of Health of Malaysia, and the Pasteur Institute, as well as the WHO’s Special Programme for Research and Training in Tropical Diseases, and Médecins sans Frontières (MSF), DNDi presents an alternative approach to drug development. It facilitates north-south and south-south collaboration, capacity building, and knowledge sharing among researchers, scientists, industry, and governments.
Conclusion (max 400 words): DNDi's current portfolio of 20 projects focuses on discovery and development projects for malaria, leishmaniasis, sleeping sickness, and Chagas disease. Its alternative approach will make new drugs available for the treatment of neglected diseases within the next decade. It is already on the road to success with its two fixed-dose artesunate-based combination therapies scheduled to be delivered to patients by the end of 2006.