Investigación original / Original research. Maria Carolina Jimenez-Marroquin, 1 Raisa Deber, 2 and Alejandro R. Jadad 2

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1 Investigción originl / Originl reserch Pn Americn Journl of Public Helth Informtion nd communiction technology (ICT) nd ehelth policy in Ltin Americ nd the Cribben: review of ntionl policies nd ssessment of socioeconomic context Mri Crolin Jimenez-Mrroquin, 1 Ris Deber, 2 nd Alejndro R. Jdd 2 Suggested cittion Jimenez-Mrroquin MC, Deber R, Jdd AR. Informtion nd communiction technology (ICT) nd ehelth policy in Ltin Americ nd the Cribben: review of ntionl policies nd ssessment of socioeconomic context. Rev Pnm Slud Public. 2014;35(5/6): bstrct Key words Objective. To exmine the vilbility of ntionl informtion nd communiction technology (ICT) or ehelth policies produced by countries in Ltin Americ nd the Cribben (LAC), nd to determine the influence of country s socioeconomic context on the existence of these policies. Methods. Documents describing ntionl ICT or ehelth policy in ny of the 33 countries belonging to the LAC region s listed by the United Ntions were identified from three dt sources: cdemic dtbses; the Google serch engine; nd government gencies nd representtives. The reltionship between the existence of policy nd ntionl socioeconomic indictors ws lso investigted. Results. There hs been some progress in the estblishment of ICT nd ehelth policies in the LAC region. The most useful methods for identifying the policies were 1) use of the Google serch engine nd 2) contct with Pn Americn Helth Orgniztion (PAHO) country representtives. The countries tht hve developed ntionl ICT policy seem to be more likely to hve ntionl ehelth policy in plce. There ws no sttisticl significnt ssocition between the existence of policy nd country s socioeconomic context. Conclusions. Governments need to mke stronger efforts to rise wreness bout existing nd plnned ICT nd ehelth policies, not only to fcilitte ese of use nd communiction with their stkeholders, but lso to promote collbortive interntionl efforts. In ddition, better understnding of the effect of economic vribles on the role tht ICTs ply in helth sector reform efforts will help shpe the vision of wht cn be chieved. Helth policy; informtion technology; Ltin Americ; Cribben region. In n incresingly digitl world, there is growing recognition tht the helth sector must integrte informtion nd communiction technologies (ICTs) t ll 1 Centre for Globl ehelth Innovtion, Toronto, Cnd. 2 Institute of Helth Policy, Mngement nd Evlution, University of Toronto, Toronto, Cnd. Send correspondence to: Alejndro R. Jdd, jdd@ehelthinnovtion.org levels, especilly t time when helth systems fce stringent economic chllenges nd growing demnds to provide more nd better helth cre services, especilly to those most in need (1). ICTs might help improve helth conditions in low- nd middle-income countries (LMICs) by strengthening disese prevention nd mngement efforts, or through effects on the broder determinnts of helth (2). The experience from high-income countries tht hve implemented lrgescle ICT inititives hs shown tht success is lrgely dependent on solid plns to hrness the power of ehelth 3 3 The use of ICT for the helth sector. Rev Pnm Slud Public 35(5/6),

2 Originl reserch Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC systems nd services (3, 4). It is therefore vluble for countries to develop policies tht could fcilitte the doption of ehelth nd guide the use of ICTs towrd the chievement of the desired gols (5). It is not cler the extent to which systemtic efforts hve been undertken to identify ntionl ICT nd ehelth policies developed or dopted by countries in Ltin Americ nd the Cribben (LAC), nd whether there is n ssocition with the socioeconomic conditions of these countries. This study exmines the extent to which ntionl ICT or ehelth policies hve been creted by countries in the LAC region, nd explores the influence of country s socioeconomic context on the existence of these policies. LAC is region with diverse demogrphic, socil, economic, nd technologicl chrcteristics (6) nd thus provides good setting in which to exmine whether such chrcteristics re relted to the implementtion of such policies. MATERIALS AND METHODS Study design A scoping review ws crried out between Mrch nd October 2010 to identify documents describing ntionl ICT or ehelth policy in countries listed s belonging to the LAC region ccording to the United Ntions (UN) clssifiction. The study protocol ws pproved by the reserch ethics bord of the University of Toronto. For the purposes of this study, policy ws defined s set of interrelted decisions tken by politicl ctor or group of ctors concerning the selection of gols nd the mens of chieving them within specified sitution where these decisions should, in principle, be within the power of these ctors to chieve (7). To define ICT policy nd ehelth policy, previously estblished definitions from the literture were used. An ICT policy ws defined s generl pln on how to bring society nd its economy forwrd through the use of ICT tht focused on specific sectors, such s helth, eduction, or dministrtion (8). An ehelth policy ws defined s set of sttements, directives, regultions, lws, nd judicil interprettions tht direct nd mnge the life cycle of ehelth (9, 10), nd frmework nd pproch for developing ehelth in country, estblished by government with the intent of chieving helth gols (3). Eligibility criteri To be considered eligible, documents hd to meet both of the following criteri: were issued by the ntionl government of ny of the 33 countries listed in the LAC region by the UN; nd estblished cler set of gols, objectives nd strtegies to guide the use of ICTs t the ntionl level (ICT policy) or in the helth sector exclusively (ehelth policy). Documents were excluded if they 1) were issued by nongovernmentl orgniztion or country not listed in the UN clssifiction; 2) were pplicble to ny sector or in combintion with other sectors (for ICT policies); 3) were pplicble to sector other thn helth (for ehelth policies); or 4) did not clerly stte gols objectives nd strtegies for the use of ICTs t the ntionl level (for ICT policies) or in the helth sector exclusively (for ehelth policies). Serch strtegy The serch strtegy included three sources of dt: cdemic dtbses; the Google serch engine; nd government gencies nd representtives. The serch of cdemic dtbses ws crried out between 18 Mrch nd 21 June 2010 nd included list of 173 terms relted to the nmes of the countries, helth policy, nd ICTs. The titles nd bstrcts were screened for potentil eligibility first, followed by review of the full text of potentilly eligible documents. Avilble policies were identified directly through the Google serch engine by using the following terms: [Country nme] AND Policy AND ehelth OR informtion technologies. The Web serch ws crried out primrily in English nd Spnish. When no relevnt link resulted, the serch ws lso conducted using the sme serch terms trnslted into Dutch, French, nd Portuguese. After the min Google serch ws completed, the officil websites of the ntionl governments nd the ministries of helth nd of telecommunictions for ech country were locted online nd serched for dditionl eligible documents. LAC government representtives were contcted online, by phone, nd fce-to-fce to verify the ccurcy of the documents identified nd retrieved online nd to inquire bout ny other vilble documents. Online contct included messges sent through posted forms nd chts nd to emil ddresses provided in the identified government websites. A rndom smple ws used for telephone clls, which ultimtely included the governments of Argentin, Bhms, Brbdos, Brzil, El Slvdor, Colombi, Guteml, Mexico, Prguy, nd Venezuel. Government representtives were lso contcted directly during the Pn Americn Helth Orgniztion (PAHO) 50th Annul Directing Council Meeting, n nnul event tht brings together ministers of helth nd selected government representtives from ll PAHO member sttes to discuss the helth gend for the region. Finlly, PAHO country representtives were contcted by emil to complete the verifiction of results. Contextul vribles The selected socioeconomic indictors included those tht 1) provided n overview of the economic, helth, nd technologicl context t the ntionl level; 2) were vilble for the countries in the study; nd 3) were published in relible sources. Dt were obtined from the Humn Development Report 2011 (11), the World Helth Sttistics Report 2012 (12), nd the Interntionl Telecommunictions Union (ITU) Mesuring the Informtion Society report for 2011 (13). The vribles included: totl popultion (ll usul residents of the country or ll persons present in the country t the time of the census) (11); gross ntionl income (GNI) per cpit (n indictor of inequlity), clculted in US$ bsed on constnt 2005 purchsing power prity (PPP) (11); totl helth expenditure (the sum of public nd privte helth expenditure clculted s the percentge of country s gross domestic product (GDP) nd comprising ll finncil resources spent on the provision of helth services, fmily plnning ctivities, nutrition ctivities, nd emergency id designted for helth, excluding wter nd snittion) (14); nd the ICT development index (IDI), composite index mde up of three sub-indices, including 11 indictors, which mesures the extent 330 Rev Pnm Slud Public 35(5/6), 2014

3 Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC Originl reserch to which countries cn use ICTs to enhnce growth nd development, bsed on vilble cpbilities nd skills required to mke effective use of ICTs nd enhnce their impct (13). Sttisticl nlysis Sttisticl nlysis ws crried out in SPSS 21.0 for Mc (IBM Corp, Armonk, New York, USA). Descriptive sttistics were used to chrcterize the countries. To explore the influence of demogrphic nd socioeconomic indictors on the existence of ntionl ICT or ehelth policy in LAC, binomil nd multinomil logistic regressions were crried out. Dt from the 33 countries in the study were included in the nlysis. The dependent vrible ws the outcome of whether country hd policy or not. Bseline covrite vlues were totl popultion, GNI per cpit, totl helth expenditure, nd government expenditure on helth. The ppropriteness of the regression models ws tested by performing likelihood rtio test to determine model fit nd the pseudo-coefficient of determintion (R 2 ) to mesure the model s predictive power. The Hosmer Lemeshow test ws lso conducted to ssess model relibility. Logistic regression ws crried out becuse it is well suited for describing nd testing hypotheses bout reltionships between ctegoricl dependent vrible nd one or more ctegoricl or continuous explntory vribles (15). A P vlue < 0.05 ws considered significnt for ll group comprisons. While the IDI rnk reported dt for more countries in the LAC region compred to the Network Rediness Index (NRI), dt were still missing for eight countries. Given the smll smple size, the IDI rnk ws excluded from the logistic regression models. Results Existing ICT nd ehelth policies The findings of the serch effort suggest tht 19 (57.6%) countries hve ntionl ICT policies nd seven (21%) hve ntionl ehelth policies. Acdemic dtbses yielded 41 potentilly eligible documents, which were reviewed in detil, but only four documents met the inclusion criteri. Of these, one mde reference to n existing ntionl ICT policy in Argentin, one ech to n ehelth policy in Brzil nd Chile, nd the fourth mentioned the existence of ntionl progrm for the estblishment of n informtion system in the helth sector nd the existence of ntionl strtegy for n informtion society in Cub, but did not directly provide informtion bout policy. The Google serch identified 19 eligible documents. Of these, 17 referred to ntionl ICT policy nd two corresponded to ntionl ehelth policy (from Belize nd Peru). Contcting government representtives through government websites ws not very helpful. The 31 countries tht hd n officil government website were contcted vi online forms, emil, or cht, depending on the vilble feture. However, none of the submitted online forms resulted in response, messges to 19 emil ddresses led to prtil response in most cses, nd only the contct for the Peruvin government responded with potentilly eligible policy document. Telephone contct lso did not produce vluble results. In most cses, there ws some difficulty in obtining response or identifying person or deprtment who ws fmilir with the topic nd who could provide useful informtion. Only representtives from Brzil nd Colombi were ble to provide informtion leding to potentilly eligible document or bout plns to develop new policies. During PAHO s 50th Directive Council meeting, the Colombin representtive ffirmed the country hd n ICT policy but did not corroborte the current development of n ehelth policy. The representtives from both Trinidd nd Tobgo nd Venezuel sid they were wre of ongoing work in the re of ICTs nd policy in their country, but only the Trinidd nd Tobgo representtive mde ny reference to specific document. Both promised to send informtion upon their return, but none hd been received by the end of In contrst, of the 27 PAHO country representtives contcted, 19 (70.3%) responded. Although most of the responses did not vry from other forms of contct with governments, three dditionl ntionl ehelth policies were identified (Cub, Ecudor, nd Mexico). Upon review of the ehelth policy of Ecudor, ntionl ICT policy ws identified for tht country s well. Tble 1 describes the finl group of ICT nd ehelth policies retrieved, nd the sources where they were found. Overview of country context Tble 2 summrizes the diversity in the LAC region with respect to demogrphic, socil, economic, nd technology context. The verge popultion ws 17.9 million, with the smllest being the popultion of the islnds in the Cribben nd the lrgest the popultion of Brzil. Hiti hd the lowest GNI per cpit nd Trinidd nd Tobgo hd the highest. The verge helth expenditure ws 7% of GDP, with St. Vincent nd the Grendines hving the lowest vlue nd Cub the highest. Cub lso hd the highest government expenditure on helth, in contrst to Hiti, where only 21.8% of helth expenses were pid by the government. In terms of ICT development, the best-rnked country ws Uruguy t number 41 nd the lowest ws Nicrgu t 114 (out of 152 countries). Logistic regression For the logistic regression nlysis, the hypothesis ws tht the likelihood tht country hs n ICT or ehelth policy is relted to its popultion, GNI per cpit, totl helth expenditure, nd/or government expenditure on helth. The null hypothesis would imply no difference between the covrites nd the existence of n ICT or ehelth policy. The multinomil logistic regression model ws creted with four ctegories in the dependent vrible: 1) no policy, 2) only n ICT policy, 3) only n ehelth policy, nd 4) both policies. The binomil model only hd two ctegories ( hs policy versus does not hve policy ) in the dependent vrible nd ws conducted seprtely for ICT nd ehelth policies. Absence of both n ICT nd n ehelth policy ws set s the reference group. Tble 3 shows the results from the multinomil logistic regression. The pseudo- R 2 (Cox Snell = 0.580; Ngelkerke = ; McFdden = 0.390) nd goodness of fit (Person χ 2 = , P = 1.000; devince χ 2 = , P = 1.000) suggest tht the fit of the model ws good. While the model fitting rejected the hypothesis (χ 2 = , P = 0.004), none of the vri- Rev Pnm Slud Public 35(5/6),

4 Originl reserch Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC TABLE 1. Informtion nd communiction technology (ICT) nd ehelth policies in Ltin Americ nd the Cribben, 2010 Country ICT policy ehelth policy Antigu nd Brbud Informtion nd Communiction Technologies (ICTs) Drft Policy Source: Argentin Pln Ncionl de Gobierno Electrónico Decreto Nº 378/2005 Source: or Bhms Brbdos Brbdos Ntionl ICT Strtegic Pln Mobile Brbdos: Building the Networked Ntion Drft Report Source: Belize Belize Helth Informtion System (BHIS) Pln Source: publictions/ntionl-helth-informtion-systemstrtegic-pln Bolivi Estrtegi Ncionl de Tecnologís de Informción y Comunicción pr el Desrrollo (ETIC) Source: Proceso.pdf Brzil Estrtégi Gerl de Tecnologi d Informção EGTI 2010 Source: Chile Estrtegi Digitl Chile Source: Colombi Cost Ric Pln Ncionl de Tecnologís de l Informción y ls Comunicciones (PLAN TIC) Source: Cost Ric: Verde e Inteligente Estrtegi Ncionl de Tecnologís de Informción y Comunicción. Source: Polític Ncionl de Informção e Informátic em Súde Propost Versão 2.0 Source: www2.dtsus.gov.br/ DATASUS/APRESENTACAO/ PoliticInformcoSude29_03_2004.pdf El Libro Azul Agend Digitl del Ministerio Slud Source: CHILE_libro_zul.pdf Cub Progrm de Informtizción del Sector de l Slud Source: de%20informtizcion.pdf Dominic Government of Dominici [sic] Informtion Technology Strtegic Pln April 18, Source: unstts.un.org/unsd/dnss/docviewer.spx?docid=2241 Dominicn Republic Ecudor Pln Estrtégico E-Dominicn Source: Agend Ncionl de Conectividd Source: ut=blog&id=38&itemid=158 El Slvdor Grend ICT Strtegy nd Action Pln for Grend ICT Strtegy nd Action Pln - Grend ( ) Source: / nd Guteml Guyn ICT4D Ntionl Strtegy Guyn Finl Drft 2006 Source: Hiti Hondurs Jmic Drft Mster Implementtion Pln for E-Powering Jmic 2012 Ntionl ICT Strtegy Source: ntionl-ict-strtegy Mexico Vision Mexico Sistem Ncionl e-mexico Source: Descrgbles/Doc_PP_vision_ Mexico_2020_resumen.pdf / nd Nicrgu Polític Ncionl de Telemedicin/Teleslud Propuest Source: Document not public t the time obtined through Ecudor s PAHO representtive Progrm de Acción de Teleslud Source: comite_e-slud/telesludcomiteinterisntitucionl. pdf (Continues) 332 Rev Pnm Slud Public 35(5/6), 2014

5 Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC Originl reserch TABLE 1. Continued Country ICT policy ehelth policy Pnm Prguy Peru St. Kitts nd Nevis St. Luci St. Vincent nd the Grendines Surinme Trinidd nd Tobgo Pln de Desrrollo de l Sociedd de l Informción en el Perú L Agend Digitl Perun Source: Government of St. Kitts nd Nevis Ntionl Informtion nd Communictions Technology (ICT) Strtegic Pln Source: unstts.un.org/unsd/dnss/docviewer.spx?docid=2297 Fst forwrd: Trinidd nd Tobgo s Ntionl Informtion nd Communiction Technology Strtegy Source: Uruguy Estrtegi y gend digitl Uruguy Source: uruguy_2008_-_2010.html?menuderecho=3 Venezuel Pln Ncionl de Teleslud Source: ftp://ftp2.mins.gob.pe/ otrspublicciones/22/teleslud.pdf The use of ICT for helth. TABLE 2. Descriptive sttistics, Ltin Americ nd the Cribben, 2010 Vrible Minimum Mximum Men Stndrd devition Popultion GNI b per cpit Helth expenditure c Government expenditure d IDI e rnk In millions (11). b Gross ntionl income (in US$ bsed on constnt 2005 purchsing power prity) (11). c Totl expenditure on helth s percentge of 2009 gross domestic product (12). d Generl government expenditure on helth s percentge of 2009 totl expenditure on helth (12). e ICT Development Index (8). TABLE 3. Multinomil logistic regression model for probbility of informtion nd communiction technology (ICT) nd ehelth policies, Ltin Americ nd the Cribben, 2010 Policy OR b P 95% CI c ICT nd ehelth Intercept d Popultion GNI e per cpit Helth expenditure Government expenditure ICT only Intercept d Popultion GNI per cpit Helth expenditure Government expenditure ehelth only Intercept d Popultion f 1.000E 013 NA g 1.000E E-013 GNI per cpit f Helth expenditure f Government expenditure f The use of ICT for helth. b OR: odds rtio. c CI: confidence intervl. d Reference: no ICT or ehelth policy. e GNI: gross ntionl income. f Floting point overflow occurred while computing this sttistic; therefore its vlue ws set to system missing. g NA: not pplicble. bles in the model showed sttisticl significnce, lthough popultion showed trend towrd significnce (P = 0.069). Tbles 4 nd 5 summrize the results of the binry logistic regression for ehelth nd ICT policies. The Hosmer Lemeshow test evlutes whether logistic regression model is well clibrted to help determine if the probbility predictions generted by it reflect the occurrence of events in the dt (16). The test does not estimte the extent of the fit. The results of the test for this study s models for ehelth policy nd ICT policy (χ 2 = 9.598, degrees of freedom = 8, p = 0.294, nd χ 2 = , degrees of freedom = 8, p = 0.146, respectively) suggest tht both models fit the dt well. However, despite the good fit of the dt, none of the independent vribles showed sttisticl significnce. Discussion This study showed tht governments in LAC countries hve begun to develop ntionl ICT nd ehelth policies. The results reveled tht five countries hd both policies, 14 hd only n ICT policy, two countries hd only n ehelth policy, nd 12 countries did not pper to hve ny. The most useful methods for identifying the policies were 1) conducting Google serch nd 2) consulting the PAHO country representtives. Serching trditionl cdemic dtbses nd Rev Pnm Slud Public 35(5/6),

6 Originl reserch Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC TABLE 4. Binry logistic regression model for ehelth policy, Ltin Americ nd the Cribben, 2010 Step 1 OR b P 95% CI c Vribles nlyzed: Popultion GNI d per cpit Helth expenditure Government expenditure Constnt NA e The use of informtion nd communiction technology (ICT) for helth. b OR: odds rtio. c CI: confidence intervl. d GNI: gross ntionl income. e NA: not pplicble. TABLE 5. Binry logistic regression for informtion nd communiction technology (ICT) policy, Ltin Americ nd the Cribben, 2010 Step 1 OR P 95% CI b Vribles nlyzed: Popultion GNI c per cpit Helth expenditure Government expenditure Constnt NA d OR: odds rtio. b CI: confidence intervl. c GNI: gross ntionl income. d NA: not pplicble. contcting government representtives did not yield high number of eligible documents. Across countries wide vribility ws found in 1) popultion, 2) GNI per cpit, 3) expenditure on helth, nd 4) ICT development. The logistic regression models did not show significnt sttisticl difference, lthough there seemed to be trend for popultion. Two orgniztions hve strted to keep trck of ICT policies nd ehelth policies in LAC. The Observtory for the Informtion Society in Ltin Americ nd the Cribben (OSILAC) is joint effort between the United Ntions Economic Commission for Ltin Americ (ECLAC) nd the Institute for Connectivity in the Americs (ICA) t the Interntionl Development Reserch Centre (IDRC) to monitor nd support the progress of regionl countries towrd the development of informtion societies (17). The Globl Observtory for ehelth (GOe) is n inititive from the World Helth Orgniztion (WHO) tht seeks to improve helth by providing member sttes with strtegic informtion nd guidnce on effective prctices nd stndrds in ehelth (18). More recently, the ITU strted reporting on the estblishment of ntionl ICT policies cross UN member sttes (8). Contrsting the serch yields with dt from OSILAC nd GOe suggested tht the current study s effort led to n incomplete picture. OSILAC, for instnce, reported tht 26 LAC countries (79%) hd ICT policies (19 21). Similrly, GOe reported in 2006 tht 12 out of 14 LAC countries for which they obtined dt hd n ICT policy, dding eight dditionl countries in 2010 (out of 10 countries) (3, 22). While GOe mde no reference to specific ICT policies tht could be trcked, OSILAC s informtion suggested tht documents from the Bhms nd Sint Luci did not meet the inclusion criteri for this study. In ddition, lthough there were some news or presenttions on the Internet mentioning potentilly eligible documents, this study ws unble to find the reported policy for El Slvdor, Nicrgu, nd Pnm mentioned by OSILAC. The study serch did not find the ICT policy for Cub, Guteml, Prguy, or Venezuel reported by OSILAC. On the other hnd, Internet reference to n ICT policy ws found for Dominic nd St. Kitts nd Nevis, neither of which ws listed by OSILAC t the time of the study. The GOe published n updted report in 2012 (23), nd this study s list of ehelth policies mtched it, with the exception of Argentin, which did not meet this study s inclusion criteri. The results of this study suggest tht there my be lck of wreness mong government representtives with respect to the development nd implementtion of ehelth policies s well s, sometimes, ICT policies. Therefore, governments need to explore vrious wys to rise wreness bout existing nd plnned ehelth policies, not only to fcilitte ese of use nd communiction with their stkeholders, but lso to promote collbortive interntionl efforts. According to Guerr & Jordn, the ntionl policy environment relies hevily on the individul country s socioeconomic nd politicl sitution, which sets the priorities for government ctivities. Their study showed correltion between levels of economic nd digitl development but noted tht even where GNI levels were identicl, some countries were mking fster progress in the use of ICTs, which they sid could be becuse those countries re more committed to nd wre of the issue, giving it plce in the policy gend nd promoting ctions gered towrd digitl development (19). An explortory model ws developed to ssess some of the fctors tht could ffect the development of n ICT or ehelth policy but it filed to identify ny independent vribles tht showed significnt ssocition. Further reserch is needed to better understnd the influence of country s context in the development nd implementtion of ntionl ICT nd ehelth policies. As governments incresingly recognize tht incorporting ICT is priority for helth systems development, collbortion between different sectors, both public nd privte, is centrl to chieving strtegic nd integrted ction (1). The chllenges posed by chrcteristics of the helth system nd fctors ssocited with ptients nd their fmilies will likely shpe the trnsformtive potentil of ICTs in the region (24). A better understnding of the effect of economic vribles on the role tht ICTs ply in helth sector reform efforts (23, 25) will help shpe the vision of wht cn be chieved, nd the scope of ctivities nd mgnitude of investment required. 334 Rev Pnm Slud Public 35(5/6), 2014

7 Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC Originl reserch Limittions The current results should be interpreted in light of vrious study limittions. First, given the strict inclusion criteri for ICT nd ehelth policies, it is possible tht documents for some countries did not meet the study criteri or exist in sources not used in the study nd were thus excluded from the nlysis. Second, the study did not differentite between developed nd dopted policies or consider policies being developed/tested (but not yet officil). As result, the uthors my hve 1) overestimted the extent/ use of ICT/eHelth policy in countries with n eligible document tht hd not been dopted yet nd/or 2) excluded countries tht did not yet hve n officil policy but hd mde progress in the re of ICT/eHelth within their helth systems. Finlly, lthough the use of logistic regression is common in helth reserch, the use of multinomil logistic regression is rre (15), which limits the comprisons tht cn be drwn from similr studies. Moreover, it is cler tht mny fctors ffect country context nd thus it is likely tht the vribles in this study s models were not sufficiently comprehensive. Conclusions The countries in LAC hve been mking progress in envisioning the incorportion of ICT nd ehelth policy within their helth systems. However, prtnerships t the ntionl nd regionl level should be strongly encourged to level the plying field for ll countries in the region to ssist them in dvncing the equitble delivery of helth services for their citizens. Further studies re needed to investigte the ssocition between the endogenous nd exogenous fctors tht ffect the bility of country to generte, implement, nd monitor ICT or ehelth policies. Acknowledgments. The uthors thnk Lur O Grdy from the Centre for Globl ehelth Innovtion, for supporting the design of the review of the literture; Mrin Engleskis from the University Helth Network (UHN), for supporting the review of cdemic dtbses; An Luci Ruggiero from the Pn Americn Helth Orgniztion (PAHO), for fcilitting the contct with PAHO/WHO country representtives; nd Adm Dimnt from the University of Toronto, for supporting the sttisticl nlysis. Conflicts of interest. None. REFERENCES 1. Interntionl Telecommuniction Union; World Helth Orgniztion. Ntionl ehelth Strtegy Toolkit. Genev: World Helth Orgniztion nd ITU; Avilble from: www. itu.int/pub/d-str-e_health Accessed on 7 My Chndrsekhr CP, Ghosh J. Informtion nd communiction technologies nd helth in low income countries: the potentil nd the constrints. Bull World Helth Orgn. 2001;79(9): World Helth Orgniztion Globl Observtory for ehelth. Building foundtions for ehelth progress of Member Sttes. 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TOTL.ZS Accessed on 7 My Jonne Peng CY, Nichols RN. Using multinomil logistic models to predict dolescent behviorl risk. J Mod App Stt Meth. 2003;2(1): LVlley MP. Sttisticl primer for crdiovsculr reserch. Circultion. 2008;117: United Ntions Economic Commission for Ltin Americ. About ECLAC [Internet]. Sntigo: UN; c2013. Avilble from: noticis/pgins/4/43024/p xml&xsl=/tpl-i/p18f-st.xsl&bse=/tpl-i/topbottom.xsl Accessed on 7 My World Helth Orgniztion. Globl Observtory for ehelth (GOe) [homepge on the Internet]. Genev: WHO; c2014. Avilble from: Accessed on 7 My Guerr M, Jordn V. Public policies for the informtion society: shred vision? Project document. Sntigo: United Ntions; Avilble from: Accessed on 8 My Peres W, Hilbert M. L sociedd de l informción en Améric Ltin y el Cribe: desrrollo de ls tecnologís y tecnologís pr el desrrollo. Sntigo: United Ntions; Avilble from: cgi-bin/getprod.sp?xml=/publicciones/ xml/2/36002/p36002.xml&xsl=/ddpe/tpl/ p9f.xsl&bse=/dmh/tpl/top-bottom.xslt Accessed on 8 My Observtory for the Informtion Society in Ltin Americ nd the Cribben. Monitoring elac2007: progress nd current stte of development of Ltin Americn nd Cribben informtion societies. Sntigo: United Ntions; Avilble from: stdev0125_en.pdf Accessed on 8 My Globl Observtory for ehelth. Atls ehelth country profiles bsed on the findings of the second globl survey on ehelth. Genev: World Helth Orgniztion; Avilble from: publictions/ehelth_series_vol1/en/index. html Accessed on 7 My Rev Pnm Slud Public 35(5/6),

8 Originl reserch Jimenez-Mrroquin et l. Informtion nd communiction technology nd ehelth policy in LAC 23. World Helth Orgniztion. The bigger picture for e-helth. Bull World Helth Orgn. 2012;90(5): Fernndez A, Oviedo E. Slud electrónic en Améric Ltin y el Cribe: vnces y desfíos. Sntigo: United Ntions nd Europen Union; Avilble from: www. eclc.org/publicciones/xml/5/41825/dislud-electrinic-lac.pdf Accessed on 7 My Ktz J, Hilbert M. Rod mps towrds n informtion society in Ltin Americ nd the Cribben. Sntigo: United Ntions; Avilble from: publicciones/xml/0/12900/rodmps.pdf Accessed on 8 My Mnuscript received on 15 July Revised version ccepted for publiction on 12 My resumen Polític en mteri de eslud y tecnologís de l informción y l comunicción en Améric Ltin y el Cribe: nálisis de ls polítics ncionles y evlución del contexto socioeconómico Plbrs clve Objetivo. Anlizr l disponibilidd de polítics ncionles en mteri de tecnologís de l informción y l comunicción (TIC) o eslud formulds por los píses de Améric Ltin y el Cribe, y determinr l influenci del contexto socioeconómico del pís sobre l existenci de este tipo de polítics. Métodos. Se seleccionron documentos que describiern un polític ncionl de TIC o eslud en culquier de los 33 píses de Améric Ltin y el Cribe según l clsificción de ls Nciones Unids, prtir de tres fuentes de dtos: bses de dtos cdémics; el motor de búsqued Google; y orgnismos y representciones gubernmentles. Tmbién se investigó l relción entre l existenci de un polític de este tipo y los indicdores socioeconómicos ncionles. Resultdos. Se h producido lgún progreso en el estblecimiento de polítics de TIC y eslud en Améric Ltin y el Cribe. Los métodos más útiles pr determinr ls polítics fueron: 1) el uso del motor de búsqued Google, y 2) el contcto con ls representciones de l Orgnizción Pnmericn de l Slud (OPS) en los píses. Prece más probble que los píses que hn elbordo un polític ncionl de TIC hyn implntdo tmbién un polític ncionl de eslud. No se observó ningun socición estdísticmente significtiv entre l existenci de un polític y el contexto socioeconómico de un pís. Conclusiones. Es preciso que los gobiernos intensifiquen ls inicitivs pr concientizr cerc de ls polítics existentes y plnificds en mteri de TIC y eslud, no solo pr fcilitr su utilizción y l comunicción con los interesdos directos, sino tmbién pr promover inicitivs colbortivs escl interncionl. Por otr prte, un mejor comprensión del efecto de ls vribles económics sobre l función que ls TIC desempeñn en ls inicitivs de reform del sector de l slud yudrá estblecer l perspectiv de lo se puede llegr logrr. Polític de slud; tecnologí de l informción; Améric Ltin; región del Cribe. 336 Rev Pnm Slud Public 35(5/6), 2014