An Environmental Scan: Educating the Health Informatics Workforce in the Global South

An Environmental Scan: Educating the Health Informatics Workforce in the Global South Judy Ozbolt, Ph.D., R.N., F.A.A.N., F.A.C.M.I., F.A.I.M.B.E. Introduction The Global South includes countries in the Americas, Africa, the Middle East, South Asia, and the Pacific where health is fragile, resources are few, and literacy is limited. While there are regions within The Global North that share some of these same characteristics to a lesser extent, typically, the infrastructure of the Global South is less adequate for both public health and clinical care. Yet information and communications technologies (ICT) are penetrating even these countries, and there are many examples of their use to strengthen health care. Critical to such use is a workforce of people who know how to select, implement, use, and support appropriate technologies. In countries where needs are great and resources are limited, how can people acquire the necessary knowledge and skills? This paper will review the scope of the challenge, describe in some detail a model program and the features that make it effective, and provide other examples of programs that are working. The paper does not attempt to catalogue all the programs that are meeting this need. Instead, these examples will highlight approaches to emulate in coordinated and systematic efforts to educate the health informatics workforce where needs are greatest around the world. The Challenge The scarcity of health workers characterizes the Global South, even as high mortality afflicts many regions, notably in sub-saharan Africa and parts of South Asia. 1, 2 Health workers with masters or doctoral degrees, including physicians, nurses, pharmacists, and dentists, are concentrated in cities. 2 Smaller towns are fortunate if they have clinics staffed by nurses with basic preparation to care for persons whose health needs range from primary to tertiary, with limited if any physician backup. Villagers rely on minimally trained health aides or traditional practitioners. Health care policies have not typically addressed the need to increase the number of health workers and improve their distribution. 2 Illness burdens the Global South, not only with care needs that exceed capacity, but also with the loss of a healthy, educated, productive population. People cannot realize their human capacities when they are too ill to work or to learn. Yet it is not feasible to provide enough health workers, with enough skills and resources, to meet the needs of all people, wherever they are. And, a brain drain of health workers to developed economies contributes to the challenge in some areas. What, then, can be done? What partnerships can be forged between the Global North, where resources are greater, and the Global South to alleviate the burdens of ill health and support the numbers and efforts of dedicated health workers who are doing their utmost to meet the needs? One strategy is to increase the focus on health promotion and prevention of illness, enlisting the participation of all health workers, from the village providers to the policy makers, in helping individuals and communities to adopt practices that will support their health. Another is to use the capacities of information and communications technologies to deliver information to health workers and to citizens at the time and place of need, so that they can make decisions in the best interest of health. 3 Used together, these strategies will maximize the benefit from the available resources. The rapid diffusion of ICT throughout the Global South opens the possibility of using these technologies to support citizens and health workers at all levels. It is critical, however, that the technologies and the applications be appropriate to the circumstances, including the technological infrastructure and the culture. It is equally vital that the changes in practice personal, professional, organizational, and 1

political be shepherded by persons cognizant of the difficulties and ramifications of change and the strategies for success. The challenge, then, is to educate a health informatics workforce indigenous to the cultures and systems of the Global South to be able to assess needs and readiness for change, from the local to the national policy level; to determine the best and most appropriate ICT solutions to meet the needs; to enlist support, financial and otherwise, for the changes; to manage the process of implementation and the concomitant changes; to evaluate the outcomes; to support ongoing use and evolution; and to do all this while assuring meaningful careers throughout professional lifetimes. A Model Program: The RAFT Network Initiated in 2000 by medical students from the Bamako University School of Medicine in Mali to acquire Internet access to continuing education after graduation, le Réseau en Afrique Francophone pour la Télémédecine (RAFT) today links participating institutions in 10 African countries and two European countries. 4, 5 Participating institutions are in Burkina Faso, Cameroon, France, Ivory Coast, Madagascar, Mali, Mauritania, Morocco, Niger, Senegal, Switzerland, and Tunisia. The University Hospital of Geneva provides overall coordination. For sustainability, the participants have secured support through champions in university hospitals, ministries of health, and related agencies, eventually integrating ehealth and telemedicine into the health strategies of participating countries. The project has responded to the grassroots demand for continuing medical education with weekly Web-casts. To enable access where international bandwidth is extremely limited, the team at the University Hospital of Geneva developed a platform that requires only 28 kb/s for high quality transmission of voice and still images of didactic materials. 6 Because the video presentation requires more bandwidth and offers relatively less educational value, users can adjust the quality of the video downward as needed. Currently, anyone may participate in the continuing education sessions, ask questions, provide feedback, and replay the lessons. The intent is to establish a community of learning and information sharing. RAFT also provides opportunities for telemedicine consultations, an activity that requires identification of participants and acceptance into the virtual community to ensure confidentiality and appropriate use of patient information. Although consultations requiring clinical examination of the patient are limited to sites with access to high bandwidth, a platform developed at the University Hospital of Basel permits the transmission of images and information, including rapid email responses from consultants, in more remote sites. 7 In Bamako (Mali), Nouakchott (Mauritania), and Yaoundé (Cameroon), WLAN connections between hospitals allow collaboration and consultations among health professionals within each capital city. To minimize use of international bandwidth in consultations across national borders, participants may log into local portals. A local team of two, one with a medical background and the other with a technical background, coordinates and supports activities in each participating agency. They receive training in skills needed to support content development and system maintenance, and they meet regularly with their counterparts from other countries. A core team of medical and ICT experts in Bamako assesses needs of new participants and provides for training the coordinators and health care professionals. A significant concern of the project has been to overcome the dominant belief that quality contents had to come from the North. 4 From the beginning, the weekly sessions have been structured as dialogues, and the content increasingly comes from the South. Indeed, professors in European hospitals now take classes in tropical medicine taught by their African colleagues through RAFT. A representative of the Health on the NET Foundation (HON) is based in Bamako to acquire the expertise to evaluate needs for online content developed in Africa. RAFT is not only meeting needs for continuing medical education and telemedicine throughout francophone Africa but in a pilot project in Mali, RAFT provides an inducement for a physician to commit to three years in a remote village. In return for providing primary care to the population, the physician receives connectivity to colleagues and family and the opportunity to pursue a degree in epidemiology from a French university via distance learning. By relieving personal and professional isolation, RAFT in this instance is bringing medical care directly to those most deprived. 8 The authors identified three key success factors for the RAFT project: 2

Institutional anchoring of these tools within national healthcare strategies; Appropriation by the healthcare professional through training, reliable routine service, and the demonstration of direct and indirect benefits; Adaptation of educational content to take into account the local knowledge and know-how, by enabling multilateral discussions during interactive distance education sessions, and collaborative online contents creation and annotation. 4 Additional success factors for consideration in other efforts to educate a health informatics workforce for the Global South include: The initiation of the demand from local healthcare professionals; The use of champions to obtain institutional and governmental support for sustainability; The recognition and incorporation of the medical and cultural expertise of the participants from the South; The presentation of informatics education as a necessary means to a desired end, rather than as an end in itself; The use of technologies appropriate to the infrastructure and the demonstration of significant benefits from these technologies; The development of local teams of expert coordinators and supporters; The development of a community of mutual respect and multidirectional learning. The RAFT project is not about creating informatics training programs. Rather, it is about meeting expressed needs of health professionals using informatics tools. The training is provided in response to a felt need to know. Systematic efforts to create a health informatics workforce must take into account how those workers will be integrated into the health care workforce and how their knowledge and skills will serve the home country s strategic objectives for health services and the health of the population. Other Programs That Work Elsewhere in Africa, ICT is also facilitating the education of health professionals. In Kenya, 70 per cent of nurses and 45 per cent of the entire health workforce are enrolled nurses who lack the full education required for licensure. Through a partnership involving the Nursing Council of Kenya, the African Medical Research Foundation, the Ministry of Health, Accenture, and four schools of nursing, distance learning methods are being used to upgrade 22,000 enrolled nurses to registered nurses by 2010. 9 In the course of this project, 192 workers have received ICT training to support the distance learning, and nurses are incidentally learning computer skills through their participation in e-learning. The program is proving much more cost effective than traditional classroom education, and it allows the students to remain on the job in their home communities. If distance education is to become widespread in Africa and the Global South to meet needs for increasing and upgrading the healthcare workforce, scalable approaches, probably involving distance learning, will be required to educate the health informatics workers to support the education infrastructure. In Brazil, for nearly two decades Marin has been developing and using distance education for nurses, especially in the area of maternal-child health, as well as teaching informatics and conducting research at the Federal University of Saõ Paulo and the State University of São Paulo. 10-12 Graduates of her nursing informatics program in the School of Nursing of the State University of São Paulo have initiated such programs elsewhere in Latin America. Likewise, graduates of the medical informatics program at the Federal University of São Paulo are part of biomedical informatics small academic elite in Latin America. Effective as these programs are, they are available only to those who can study in Portuguese. Fluent in Spanish and English as well as Portuguese, Marin often consults elsewhere in the Americas. She and the other academic leaders in Brazil are doing a great deal to develop an indigenous, highly skilled, culturally aware informatics workforce in Latin America, but much more is needed. In North America, Australia, New Zealand, and Europe, distance education in informatics is well established. To make such training more widely available, the American Medical Informatics Association has created its 10 x 10 program (10,000 health professionals with basic training in informatics by 2010). 13 Informatics courses offered at accredited universities are reviewed by a committee of AMIA members and, if approved, are made available to any interested persons through the 10x10 program. The first university to partner with AMIA in this program was Oregon Health and Science University (OHSU), which offered its introductory course through 10x10. Although AMIA s 10 x 10 courses are open to students anywhere in the world, they are in English, and the content is in some areas specific 3

to the United States. In a pilot program, OHSU collaborated with the Department of Medical Informatics of the Hospital Italiano de Buenos Aires, Argentina to create a 10x10 course suitable for Latin America. 14 The Argentinean team translated course materials into Spanish and created a handbook of more than 700 pages to compensate for the lack of Spanish-language textbooks in informatics. They removed material specific to the United States and added material better adapted to Latin American needs, such as a greater emphasis on public health. They designed the content to be accessible even from a dial-up Internet connection. Of the 152 students who enrolled in the course in 2006, 142 completed it. Students rated the course highly and expected to use their new knowledge in implementing electronic health records and other health informatics applications. The Latin American experiences, like the projects cited in Africa, demonstrate the feasibility of using ICT to offer informatics education in the Global South. Imparting knowledge, however, is only a small part of creating an educated, effective workforce. Each example has shown the importance of a strong, well-prepared team of indigenous professionals to guide the work, obtain and sustain support, and assure the suitability of educational content to local needs. Some Thoughts on Program Content The content to be included in educating the informatics workforce for the Global South or elsewhere is far from decided. A recent discussion on AMIA s Academic Forum list serve (June 6-13, 2008) has revealed a wide range of views on the essentials to be included in a graduate program. Hersh s 2008 review paper. [15] captured the diversity of opinions and the breadth of the field from an international perspective. In North America and Europe, doctoral programs and many master s programs have aimed to prepare researchers to advance the science of biomedical or health informatics. Master s programs in nursing informatics, by contrast, have focused on preparing mid-level workers to manage the life cycles of clinical and educational applications: needs assessment, readiness, process analysis and redesign, system selection, training, implementation, change management, evaluation, and ongoing support and evolution. Curricular content includes informatics principles and skills, financial management, organizational processes, and change management. 16,17 Some of these nursing informatics master s programs, like that at the University of Maryland, may be pursued entirely online. With adaptation to local needs and constraints, such programs might offer a scalable resource to prepare health informatics workers in the Global South. If academic programs from the North are to be adapted and offered in the South, and enriched by contributions from the South, it will be critical to determine the mix of knowledge and skills needed in the South and to match the students to the programs that will best serve them and their countries needs. Conclusion Informatics will provide important tools to transform health policies, health services, and the health of populations worldwide. In the Global South, international partnerships offer resources to build a workforce with the diverse skills and local knowledge needed to implement and sustain appropriate technologies. Many more initiatives than the few described here are underway. Each of these examples offers important lessons for scalability, sustainability, and success. First among these is the involvement of local health professionals in all phases of the work, so that their knowledge can shape solutions that work in the particular circumstances. Second is the imaginative use of technologies that provide real benefits while operating under constrained resources. Third is the integration of informatics initiatives, including workforce development, into the strategic plans and policies of the host countries. Incorporating these lessons into new, larger, more coordinated efforts will be critical to developing the health informatics workforce in the Global South. 4

References 1. World Health Organization. WHO estimates of health personnel: Physicians, nurses, midwives, dentists, pharmacists. Geneva, 2004. Retrieved June 13, 2008 from http://www.who.int/globalatlas/autologin/hrh_login.asp. 2. Joint Learning Initiative. Human resources for health: Overcoming the crisis, p. 3. Cambridge, MA: The President and Fellows of Harvard College, 2004. 3. Mundie C. Information technology: Advancing global health. NBR Analysis 2006; 17(2), 3-21. 4. Geissbuhler A, Bagayoho CO, Ly O. The RAFT network: Five years of distance continuing medical education and tele-consultation over the Internet in French-speaking Africa. Int J Med Inform 2007;76:351-356. 5. Geissbuhler A, Ly O, Lovis C, L Haire JF. Telemedicine in western Africa: Lessons learned from a pilot project in Mali, perspectives and recommendations. J Am Med Inform Assoc Suppl 2003: 249-253. 6. http://www.unige.ch/ecours. 7. Brauchli K, O Mahony D, Banach L, Oberholzer M. ipath A telemedicine platform to support health providers in low resource settings. Stud Health Technol Inform 2005;116:891-896. 8. Biltman S. La télémédecine, remède à l isolement. Africa International 2006;394:32-33. 9. http://www.amref.org/info-centre/amref-courses training-programmes/elearning-program. Retrieved June 15, 2008. 10. Marin H de F. Informática em enfermagem/computer science in nursing. São Paulo: EPU, 1995. 11. Marin H de F, Paiva MS, de Barros SMO. AIDS e emfermagem obstétrica. São Paulo: EPU, 1991. 12. Da Motte MCS, Marin H de F, Zeitoume RCG. Desenvolvimento do software educacional em saúde do lactente/development of an educational software in pediatrics. Esc Anna Nery Rev Enferm 2001;5(2):211-223. 13. http://www.amia.org/10x10/. Retrieved June 15, 2008. 14. Otero P, Hersh W, Luna D, Osornio AL, de Quiros FGB. Translation, implementation and evaluation of a medical informatics distance learning course for Latin America. MEDINFO 2007: 421-422. 15. Hersh W. Health and Biomedical Informatics: Opportunities and challenges for a Twenty-First Century profession and its education. In Geissbuhler A, Kulikowski C, eds. IMIA Yearbook of Medical Informatics 2008. Methods Inf Med 2008; 47 Suppl 1:138-145. 16. http://nursing.umaryland.edu/informatics. Retrieved June 15, 2008. 17. http://www.nurs.utah.edu/programs/masters/specialty/informatics/study_inform.html. Retrieved June 15, 2008. 5