Comparative study on system requirements and success factors of telemedicine solutions in resource-poor settings

Abstract

Rationale: Attempts to successfully develop telemedicine solutions by specifying the require-ments and critical success factors of these solutions are on-going in sub-Saharan Africa (SSA) countries as a means of improving access to high-quality healthcare. European Space Agency (ESA) (Dario et al. 2005) have explored the challenges and benefits of telemedicine solutions in these regions in the domains of eGovernment such as billing and administrative data management to support the healthcare process, aggregation and reporting of administrative data including quality, clinical outcomes, improving decision making through access to information and ad-vocacy through modern technology. This thesis builds on from the comparative analysis of the healthcare systems in Ghana and Nigeria, in order to specify the system requirements for teleme-dicine solutions supporting health governance in these countries.

Motivation: Relevant literature in the domains of public health and information systems (IS) which studies requirements and success factors of telemedicine solutions in SSA countries sug-gests specific attention to be paid to the ability of such solutions to support health system gover-nance. This is due to the complex institutional context involving technical, legal, organizational, and financial issues to be solved which makes it difficult to transfer decision-making, planning, budgeting, management and resource allocation from the national level to the country-regional, district, sub-district and community levels (Braa et al. 2001).

Method: This thesis performs a thorough review of published evidence to acquire information on the governance structures of healthcare systems in Ghana and Nigeria as well as successful operative telemedicine applications and services in these countries. UML modeling of the struc-tures is used to describe the processes which link the national level to the level of the (Regional Economic Communities) RECs of which these two countries are part. The open source District Health Information System 2 (DHIS 2) developed by Jørn Braar and collaborators is analyzed to assess functionalities it has to support health governance and health system management. The system is also analyzed in terms of what it stores, its extensibility and scalability by functions. A structured interview on health system governance in Ghana and Nigeria is conducted with key respondents such as health workers, persons dealing with statistics and training, system users, Health Information System (HIS) managers and planners. The research questions are tailored towards decision making processes in the running of healthcare system from national level to community level. Issues around funds, budgets and resource allocations are discussed. Decisions made with regard to the implementation of health policies such as the implementation of new types of healthcare services (i.e. eHealth services) are also discussed.

Results: A main finding in the thesis is that the development of information systems at district and Primary Health Care (PHC) levels in Ghana and Nigeria needs to be an integrated effort across health sectors. With this focus, requirements and critical success factors of telemedicine solutions for Ghana and Nigeria have been specified by assessing the governance structures of health services in the two countries and by analyzing the DHIS 2 to identify scenarios in health-care that need telemedicine support. In the case of Ghana, the local control and empowerment of information at lower levels should be embedded into PHC. This is due to the fact that the man-agement of the source of healthcare information is usually a top-down approach (from national level to lower level) toppled with the differences that exists in the collection of healthcare data. This causes delays in healthcare decision making and duplications and omission of key data sets for performance assessment by the government. As such, the DHIS 2, although being used for information reporting in the Ghanaian healthcare system extended in terms of functionalities it is proposed as a system to support healthcare governance. In the case of Nigeria, there exists a Na-tional Health Management Information System (NHMIS) as a management tool for informed decision making at all the levels of government in Nigeria. However, there is no clearly defined role of the different tiers of government which affects the proper functioning of the NHMIS in terms of data input and data quality. As such, integrating the DHIS 2 to be used alongside the NHMIS at the Local Government Areas (LGAs) may enhance data quality and improved infor-mation reporting in healthcare decisions.

Conclusion: Telemedicine and eHealth activity around developing countries is increasing, and this fact cannot be denied. Although such activities could be a daunting task, they are emerging as a promising means for achieving quality healthcare. The specific healthcare situations in Ghana and Nigeria have resulted in the specification of seven requirements regarding to the utili-zation of a HIS (specifically the DHIS 2). This is hoped to assist in the effective governance of healthcare systems in these countries.