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Interview

INTERVIEW

The E-Health Connection: Information And Communications Technology And The Developing World

PROLOGUE: Sophisticated information and communications technology in health care—sometimes dubbed "e-health"—is no longer a futuristic fantasy for the developing world. In low and middle-income countries, there’s growing use of everything from electronic health records to mobile phone–based systems of ensuring drug adherence. The challenge is to optimize the use of these technologies in ways that translate into gains in fighting disease and improving population health.

For four weeks at its famed conference center in Bellagio, Italy, last summer, the Rockefeller Foundation convened representatives from nearly forty countries—international policymakers, private-sector players like Intel and Microsoft, and donors—to draw up a roadmap for meeting that challenge. By the conference’s end, they had contributed to a Call to Action in the areas of e-health policy and agenda setting, fostering collaborative networks, and building capacity and knowledge. Participants agreed on key objectives, including the creation of a global compact on e-health; promoting person-centered, integrated, and interoperable systems; establishing a "virtual" entity to test e-health applications; and fostering many more public-private partnerships to push e-health applications forward in the developing world. As one enthusiastic participant, Merceline Dhal-Regis, chief medical officer of the Ministry of Health, Bahamas, put it: "E-health provides a vehicle for delivering on the promises of the [Declaration of ] Alma Ata thirty years ago"—where primary health care was identified as a critical means of advancing health worldwide.

At the foundation’s invitation, Health Affairs’ editor-in-chief Susan Dentzer participated in the final week of the conference. The special guest that week was President Paul Kagame of Rwanda, the East African nation that is still recovering from the horrific 1994 genocide. President Kagame spoke of his nation’s accomplishments in e-health to date, including its success in using TRACNet, a mobile phone–based system that allows tracking the use of anti-AIDS drugs through text messaging. President Kagame also identified future goals for his nation, where per capita annual income is an estimated $260 and growing. Both broadband wireless coverage and a national fiberoptic network are set to be in place throughout Rwanda by the end of 2009. The nation also plans to be the first among the countries participating in the U.S. Global AIDS Initiative, or PEPFAR (the President’s Emergency Plan for AIDS Relief ), to create a national HIV-AIDS patient registry.

Dentzer sat down with President Kagame and Rockefeller Foundation president Judith Rodin to discuss the future of e-health in the developing world and the foundation’s role in moving it forward. The following contains excerpts from that conversation.

E-Health And Fighting Disease

 
Susan Dentzer: President Kagame, welcome. You’ve said that Africa cannot defeat poverty unless it addresses the precarious state of health across much of the continent. How will e-health enable Rwanda to address HIV, AIDS, malaria, and other preventable diseases, as well as a probably increasing amount of other chronic disease in the future?

President Paul Kagame: Information and communication technology is an "enabler"—it provides an enabling environment for efficient delivery of social and economic services. It makes a lot of sense to therefore focus on e-health. An example of an e-health technology we are already using is TRACNet, developed as a partnership with Voxiva and our country, with PEPFAR support. Really, all it does is build on a simple two-line mobile telephone, and uses this to track drugs, patients, and what is going on between them. It helps us monitor and evaluate what’s going on with drugs even in remote areas of our country, and the progress as it relates to the patient. Normally, people do not understand it until they see it work, and in Rwanda this is now working for real-time delivery of information and enabling the system to make the appropriate response depending on the patient.

Dentzer: Do you think TRACNet was instrumental in enabling Rwanda to meet the anti-retroviral treatment goals set under the U.S. Global AIDS Initiative, or PEPFAR?

Kagame: It has certainly made a huge impact on being able to deliver. What PEPFAR has done also is to make sure that there are the resources required to get enough medicines to cover a large area of our country and the biggest part of our population. I’m sure those who have been behind PEPFAR feel that it is money well spent.

Dentzer: You’ve spoken about resources that are wasted in developing countries—drugs that are diverted, not tracked; drugs that aren’t used before they’ve expired. In spite of tools like TRACNet, do you feel there’s a longer distance to travel before there really is effective management and use of those resources?

Kagame: First of all, there is a very clear lack of resources. But when we get those resources, then we are the ones who should be most concerned about making sure that the resources are optimally put to good use. And you can only do that by being efficient, and in being efficient you therefore look to some of these tools to make sure that the efficiency required is achieved. Information and communications technology is one of those tools, and, therefore, it is the way to go.

Technology Partnerships

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: You’ve said that the use of TRACNet will be spread beyond dealing with HIV/AIDS to a number of diseases and indeed broader health issues, in an initiative called "Phones for Health." What is the status of those efforts?

Kagame: There is good progress on that. We are also growing our own information and communications technology infrastructure from the capital, Kigali, out to the local districts. As we do that, we are not only deepening the use of TRACNet to monitor HIV drugs and patients, but we are also extending it to malaria and tuberculosis, for monitoring the delivery of drugs, the levels of medical stocks, and other key information in the health system.

Dentzer: Much of this investment in the information and communications technology infrastructure in Rwanda is coming from the private sector. For example, Korea Telecom is helping Rwanda install the nationwide fiber-optic network. You’ve found it necessary to grant the private sector some incentive to do that, in terms of tax relief. Why is it so important to partner with the private sector to extend all of these capabilities?

Kagame: It’s very important to ensure that the whole situation is not to be seen as if the government is going to do everything. It’s a natural fact that the government can’t simply do everything. The government has its own limitations, and there is a very huge potential on the side of the private sector. So we seek to have public-private partnerships as the way to go. The private sector brings in a lot of innovation, entrepreneurship, and resources, and these activities they invest in are also profitable. We are benefiting from the standpoint of health, and we are able to cover more ground through partnerships than ever before.

Vision For Health

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: What is your vision for Rwanda and the connection between health improvement and e-health in, say, twenty years?

Kagame: It’s to ensure that the people of Rwanda—all the patients—once they have any problems, that they are able to have these problems solved beyond the limitations of the places where they are. That means that they can access high-quality care from beyond where they are located, or even outside their own country. And I see that in twenty years, people are actively participating in creating an environment where their problems are addressed. They are part and parcel of that process of solving their problems. I think this is, therefore, a world that for every problem you have a process that will address it in a timely way, and that this technology reaches most of the people and gives the best quality of health to the people of Rwanda and beyond.

Dentzer: You’ve spoken about mistakes that have been made in the past on the part of both donor and recipient countries, whereby donors have thought that they had all the answers, while recipient countries perhaps misused resources. How do you anticipate avoiding those mistakes going forward? What does Rwanda most need from donors to accomplish the vision that you’ve described?

Kagame: In Rwanda, we question ourselves. We look back five years, even forty years, and ask what has been going on to the extent that we are at this level of development. The immediate thing that comes out is that something must have gone wrong, because the same donors we have today are the donors that were there at that time, and they have been spending large resources in Africa.

So either one of us, but most likely both of us, did something seriously wrong. So we have to make sure that something changes. And what we are telling our development partners, the donors, is that it happens today that they have resources, whether financial or technological. But this is not enough to deliver for the long term, for the people of Africa, or even Rwanda.

If the people of Rwanda are not at the forefront of dealing with this situation, then it will be like it has been in the last forty years. Rwandese, or Africans, must take ownership. They must feel that these are their problems, and therefore they must be part of the solution. There has also got to be partnership, and there has to be an accountable process of identifying problems and then finding solutions, and accountable utilization of the resources from whatever sources.

Dentzer: Do you think that is in place now in the e-health sphere? Do you sense that willingness on the part of donors to be a partner?

Kagame: In Rwanda, yes. I’m beginning to see that happen in health care systems that we’re building, and applying e-health tools and systems. In some other areas, we still have to discuss with our donors the best way we think that our resources could be better utilized. In fact, to be very specific, there are cases in which Rwanda is perceived to have been given, say, $50 million to invest in our health sector or health care systems of one kind or another—and then actually what is put to good use is probably half of that, or less than half of that. The rest cannot be accounted for. It doesn’t just get lost; it has gone to intermediaries, or sometimes back to where it has come from, instead of making an impact on the ground where it was intended to have that impact. But those are issues that people can talk about and correct. It’s a process. People need to discuss, to debate, to find out the best way things can work.

Partnerships In Africa

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: What role can Rwanda play vis-à-vis all of East Africa in particular, but also more broadly sub-Saharan Africa, in engendering the extension of e-health as this conference has been discussing?

Kagame: We’ve been seeking to share experiences with our neighbors or partners in Africa. We show them how things have worked for us, and therefore could work for them, or even work better for them, perhaps, than they have worked for us, depending on how they manage the processes involved.

Secondly, we also seek to develop infrastructure that we share, that will bring us closer, that will enable us to share information. An example is the broadband network that we are developing in the East African Community [EAC]. Each individual country is trying to develop this broadband network, and we are looking at linking all of that together, and later on being able to link it with the undersea cable that will be surrounding the whole of Africa and linking it to the rest of the world.

Sometimes there are difficulties. Countries tend to look at themselves as [separate] countries. But with the spirit of integration that we are encouraging, we seem to be overcoming that. And Rwanda is trying to emphasize the broader benefit of bringing things together, of integration, of sharing information, of sharing infrastructure, of sharing experiences and best practices, and therefore very cost-effectively dealing with most of the challenges we face.

Dentzer: And does that extend to the whole of sub-Saharan Africa, given the very different context, say, between East and West Africa?

Kagame: I believe so. I think as we have these developments in different regions of our continent, we also want to go another step by linking these regions and later on seeing Africa as one continent, as one geographical space that will share different experiences, different best practices for the common good of the Africans.

This is happening—sometimes in a fragmented way—but the challenge is now to bring all that together and make sure that we don’t have pockets of success stories and then other areas completely in the dark. In some places, things are moving faster than in other places, but I think we can keep working at it and making sure that in another ten years or so we have made significant progress.

Rockefeller Foundation Role

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: I want to turn now to you, Judith Rodin. How is it that you view this conference as being part and parcel of what the Rockefeller Foundation is trying to accomplish in terms of moving to a twenty-first-century vision for "smart globalization"?

Judith Rodin: Partnership is leadership for the twenty-first century. The problems are very complex; the interactions and structures are more complex. If you solve things in silos, you always remain in silos. That’s what we believe is the twenty-first-century opportunity—to take these issues to bring resources together, to bring partnerships together, and to create an enabling environment for progress.

Our work in the enabling environment will focus on four things. We’ll focus on partnerships, and this meeting, in a sense, is part of that partnership-enabling environment. It’s not only about information and communications technology. It’s about bringing stakeholders together across all of the sectors to not only forge partnerships, but create new kinds of ideas.

The second is capacity building—that the capacities have to be within country in order for real sustainability and scalability. Capacity building has been too intermittent, in our view, over the last forty years, and it hasn’t been part of an integrated structure.

The third element is innovation. There is tremendous innovation going on. We see it in the private sector, and I think that’s part of the appeal of working with the private sector more directly. But we see it from the ground up—extraordinary innovation coming out of, in some cases, adversity that leads to finding new ways to do things. That innovation needs to be fostered, systematized, and taken to scale.

And then finally, and I think quite importantly, we focus on what we are calling "impact investing." What’s the twenty-year vision? What does impact look like? We need to define success clearly, and then define the benchmarks that will lead to success. If we don’t have a shared vision of success, it’s no wonder we sometimes fail. I think we’ve shortchanged ourselves in the past by not thinking about that sufficiently systematically.

Dentzer: So what is the shared vision, then?

Rodin: Our shared vision is to have globalization’s benefits shared more broadly by more people in more places. That’s a very broad vision. But the microeconomics show that that’s not happening—and it’s not happening within developed countries, it’s not happening within developing countries. So countries, macroeconomically, are lifting themselves up. But the internal inequalities are growing. We want the benefits to be spread more broadly. We want more people lifted while at the same time we avoid having the middle class slide into vulnerability because it is threatened by some of the unintended and unexpected negative consequences of globalization.

Vision For E-Health

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: This setting here at Bellagio has given birth to some extraordinary initiatives over the years, including what became the International AIDS Vaccine Initiative and the Global Alliance for Vaccines and Immunization, or as it is now known, the GAVI Alliance. What in your wildest dreams would you envision coming out of this conference on e-health?

Rodin: I think there is a tremendous opportunity, if the work coming out of this gets it right, to have developed the true model for inter-operability. We are so limited in the United States by the huge financial investments we’ve made in systems that can’t communicate, and so it is challenging us not only financially, but in terms of health care delivery, in a very significant way. As the many countries in sub-Saharan Africa tackle these problems, under the enlightened policies and leadership such as we see from President Kagame, Africa could get it right, first. That is an extraordinary vision, and it is one that emboldens the people at this meeting to think that they can work together to help make that happen.

Dentzer: Do you concur with that, President Kagame?

Kagame: Yes, I do. Africa has gone through a lot that should have taught all of us lessons. There are problems, there are challenges, but also all kinds of possibilities to deal with those challenges. It’s up to Africa to make the choice and to develop the will to move forward. And I think some of the experiences we have just discussed, some of the success stories in my own country and other countries, should be broadened and moved forward as fast as possible.

Action Steps

Top E-Health And Fighting Disease Technology Partnerships Vision For Health Partnerships In Africa Rockefeller Foundation Role Vision For E-Health Action Steps

 
Dentzer: What do you think are the next most important action steps coming out of this conference?

Rodin: We need to bring real resources to the table. We need to demonstrate that there are real markets for the private sector to participate in. We need to demonstrate that the kinds of policies that President Kagame has instituted in Rwanda are policies that enable all of these sectors to interact.

This really isn’t about finding low-hanging fruit, or doing a few pilots here and there. This is about galvanizing transformational change. And so it’s going to take big ideas with some risk-taking, but a willingness to again define that vision and take these risks together with the goal of transformational change.

Dentzer: Just to take the concept of inter-operability, will that require a working group to fashion an Africa-wide or even worldwide interoperability standard? As you mentioned, the United States hasn’t yet achieved complete agreement on interoperability standards. What’s the mechanism that enables this to happen in a developing world?

Rodin: The U.S. didn’t have a blank page, and we don’t have totally blank pages in Africa, but the continent has a blanker page—and I think a greater recognition that some of the mistakes the U.S. or the U.K. have made are learnings, and Africa can take those learnings and create opportunities.

I don’t think there’s anyone who would believe today that it’s smart to have multiple systems that can’t talk to one another. Interoperability doesn’t mean rigid common vendors; it means an architecture that all the various vendors can speak to. One of the things that I’ve been impressed by is the eagerness of the private-sector vendors to do this, whether it’s various mobile companies or the IBMs, or Microsofts, or Intels, or Ciscos—all of which have been here talking about their view that there is a need for interoperability. If that doesn’t happen out of this meeting, through some common organizing unit to address that, I think we will be very disappointed indeed.

We’ve seen many good ideas here. There have been thirty-four donors here in one way or another across the four weeks, and so we expect to galvanize the partnerships that include the governments, the donors, the academics, and the private sector to move forward, and to do it in real time.

Foundations like to say that we have the ability to take a long view. We’re not looking at the next quarter’s results, or the next election. But we don’t want to take too long-term a view. As the groups here have said, let’s get a set of three-month goals, and then a set of six-month goals, and then a set of one-year goals, and I think in this case that’s both doable and absolutely necessary.

So we feel energized, and I know our partners in the bilateral and multilateral as well as foundation communities who have been here feel the same way. There are many challenges, but many opportunities, and we think there is a wave, a momentum that is occurring, and if we can make that wave crest at the right time, this is doable.

Kagame: I would most certainly want to thank the Rockefeller Foundation and Judith Rodin for putting together such a conference, and drawing in expert resources that have been very helpful and enlightening to all of us. As I share our country’s experiences, I’ve also learned a lot from the experience brought in by others, so I just wanted to say it’s a journey that we want to travel and make sure we reach where we are going. Getting together like this facilitates that journey, and I can only say I am happy to be a part of the movement that was being talked about, and we want to build on that to keep taking our country and our continent forward.

Dentzer: And Dr. Rodin?

Rodin: I thank President Kagame for his energy and leadership. I would add from the broader perspective of the Rockefeller Foundation that health is a wonderful metaphor for what we think is our real mission and our real goal. We focus on healthy people, but they are part of healthy communities and healthy nations, and ultimately a healthy common outcome. So if we can focus on health as a way of lifting people up, and of preventing disease and war and all of the things that I think so many of us worry about in the future, I think we will have a very welcome opportunity to change the world.

Editor's Notes

 
Paul Kagame became president of Rwanda in 2000. He had been that country’s minister of defense and vice president since 1994. Judith Rodin is president of the Rockefeller Foundation in New York City. Susan Dentzer (sdentzer{at}projecthope.org) is editor-in-chief of Health Affairs.

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