By Julian Atim, MD, MPH, MBA
Coordinating Introduction of Digital Health: Lessons Learned from Uganda
Government Takes Charge
Work was interrupted when the Ugandan Ministry of Health (MOH) placed an indefinite injunction on operations that involved the application of any mobile, electronic or information health technologies. My plans to apply digital health in detection of Tuberculosis in the private health sector stalled.
CLING! That was the sound of an incoming email from the Managing Director (MD) of our nonprofit. The message was labeled high priority. I quickly read the infamous letter attached to the email. To my surprise, it was from the Ministry of Health of the government of Uganda. MOH had declared a moratorium on the operation of any mobile, electronic or information technology healthcare applications until the national eHealth policy and strategy were finalized. A few mhealth projects that met certain requirements aligned to envisioned strategy were approved to continue operating. A quick Google search of the new word “moratorium” made me better understand the implication of the letter.
A loud phone ringing sound “TUTU TUTU TU” interrupted my thoughts. Who could it be? I quickly picked up the phone and answered, “Hello?” “Hi, Julian,” said the MD on the other side of the phone. “Did you see my email?” she asked. “Yes,” I affirmed. “Could you please read the letter and come to my office with Lea and Duncan right now?” she continued.
Lea was the Communications Officer who ran the company text messaging and social media platforms. She had worked on several projects that employed mobile health to communicate with thousands of health workers, who served in about 300 private clinics that were part of the quasi-social franchise that the organization managed. This initiative built on the success the platform had created in social marketing health products nation-wide.
I dashed to the MD’s office which was one floor below my office.
“Hello”, the MD ushered us into her office. “You are aware that our organization has been working on several mobile health-related interventions. From now on wards, please make sure that we do not engage in any activities that violate the moratorium until we receive future updates from MOH regarding this issue,” said the MD.
I felt disappointed and deflated. This would impact an important strategy that applied mhealth to increase assessment and identification of people suspected of having tuberculosis (TB), part of integrated health care delivery in the private health sector.
As my mind raced to find alternative ways to deal with this setback, I was surprised by Lea’s reaction to the situation. She was calm, composed and seemed ready to continue with her other digital marketing initiatives to utilize the SMS media platform and social media. Projects develop work plans with the hope of implementing activities as planned. Navigating the uncertainty of environmental, policy and other unforeseen circumstances requires Lea’s mindset. In any line of work, it is crucial to move on quickly in the face of such challenges to continue progressively.
Was the Moratorium necessary?
In 2010, over 50 mhealth and ehealth projects were operational concurrently in Uganda, with some initiatives overlapping in terms of product features within the same region and/or health facilities. Health workers felt overburdened and burnt out from having to make multiple data entries for the same information into different data platforms. There was no collaboration or information sharing, and uncoordinated implementation among ehealth projects. A situation that caused duplication of work, wastage of resources, and barriers to early adoption and application of digital health among health workers.
MOH took charge of overall coordination of all digital health initiatives and worked towards information sharing and elimination of geographical and program overlap among innovators. Development partners and the government were reluctant to fund digital health initiatives because the chaos created by early innovators had made it difficult to ascertain the benefits of digital health. This situation was referred to pilotitis, a term I later learned meant “inability to breakout of the pilot stage.”
MOH aimed to align digital health programs to national standards that would build on existing paper-based reporting systems, indicators and report timing. Operating parallel health information systems within the existing health system would hinder these goals. MOH’s policy effort was a catalyst for innovators to design digital health initiatives with sustainability in mind.. What the Ugandan government was trying to achieve in digital health initiatives is consistent with some of the digital health governance frameworks recommended by other global entities such as the African Development Bank, and WHO.
Did the government achieve its objectives?
The Moratorium came with several benefits to the national efforts in digital transformation of health information. Here are two examples:
- Cost-reduction negotiations with mobile network operators: Negotiations with telecommunication companies created opportunities for cost reduction for digital health. For example, village health teams (VHTs) had options for free report submission, an initiative that facilitated the scale up of DHIS2. These reports were free because of negotiations.
- Immense progress in digital health: Tremendous strides had been made towards introduction of digital health as part of the broader existing health management information system (HMIS). For example, the Surveillance, Monitoring, Evaluation and Operational Research Technical Working Group on which I served designed and tested a dashboard to provide MOH’s senior management with real status of key priority health areas such as number of malaria cases and malaria positivity rates. A 100% eHMIS initiative was operational in Iyolwa Health Center III, Tororo, located in one of the regional with the highest malaria prevalence and case incidence. I will share about this initiative in a separate post.
Years later, I was in a Technical Working Group meeting organized by the Division of Health Information at the MOH in which Dr. Jane Acen, who was then the Director General of Clinical Services, officially communicated that the moratorium was lifted. Hearing the word moratorium took me three years back to the time I learned the meaning of the moratorium and how I had to change my program strategy to accommodate MOH’s guidance on digital health implementation in Uganda. This was my Eureka moment. It was a new beginning for digital health characterized by alignment of initiatives to national policy and priorities. It felt like drinking cool water on a sunny day after walking under the sun having missed the commuter minibus. I could feel the cool breeze of innovation.
I was impressed by Dr. Acen’s grip of the terminologies and concepts of what was being discussed in the meeting. She occasionally added her thoughts with simplicity to clarify difficult concepts related to digital health that was being discussed. Using simple language was suggested by Daniel Kanehein in his book Thinking Fast and Slow and a Harvard Business Review article on effective communication as key to enhance understanding is communication.
Similar Government Initiatives Globally
Currently, the FDA, WHO, US government and other key stakeholders are putting in place mechanisms to facilitate growth of digital health to add value to the healthcare industry and create impact to populations.
For instance, the FDA recently developed a white paper on certain standards guiding the development and post market monitoring of Artificial Intelligence (AI) and Machine Learning (ML) tools. Several regulations have been developed to regulate Health Information Technology including Electronic Medical Records (EHR) in the U.S.A Early regulations focused on “meaningful use” as pre-requisites for reimbursement from Medicare and Medicaid. For example, financial incentives for meaningful use certified EHR. All these federal initiatives in developed countries such as U.S.A are aimed at increasing efficiencies in adoption and continuous use of digital health interventions for best value to customers and high impact on key stakeholders.
The regulatory tool the government of Uganda applied to digital health implementation science gagged efforts by early implementers of innovations in digital health to create an environment for sustainable introduction, scale up and mainstreaming of digital health into existing health systems. Government efforts helped to create partnerships between developers to align digital health to national level priorities amidst limited resources.
As a key decision maker and payer for health, it is critical that government takes part in the creation of new initiatives in healthcare to mitigate the chaos that comes with uncoordinated efforts by multiple players. Consequently, stakeholder will maintain reasonable requirements on health workers who are end users of these inventions and create social impact to the population served.
This post was inspired by discussions on a panel discussion that came up on the role of regulation and policy in health technologies in I participated in. I was also influenced by a question an author asked me about my comment on his linked article related to the role of decision makers in development and application of digital health.