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1st International Multi Disciplinary Conference – 23-25 August 2017, Lusaka Zambia
Community Engagement for eHealth in Masvingo,
Zimbabwe
Joseph Bishi
SolidarMed
Masvingo, Zimbabwe
j.bishi@solidarmed.ch
Amadeus Shamu
Ministry of Health and Child Care
Masvingo, Zimbabwe
amashamu@yahoo.com
Janneke H. van Dijk
SolidarMed
Masvingo, Zimbabwe
j.vandijk@solidarmed.ch
Gertjan van Stam
Scientific and Industrial Research and Development Centre
Harare, Zimbabwe
gertjan@vanstam.net
Abstract— The health system in Zimbabwe is facing challenges
in the provision of equity and quality health care, especially in the
rural areas. In response, this has resulted in mounting interests in
the potential of eHealth (application of Information and
Communication Technologies in the health sector) by the
Government of Zimbabwe through the Ministry of Health and
Child Care. The Ministry of Health is focusing on the gradual
improvement of existing and new health systems involving the
incorporation of Information and Technology to optimise the
current health care system.
The hypothesis of this paper is that eHealth has the potential
of advancing health care to better health outcomes and improved
cost efficiency of care. This paper presents the potential of eHealth
and mHealth (application of mobile technology for health, as part
of eHealth) to facilitate equity and quality health care.
In conclusion eHealth and mHealth hold potential to improve
and optimise the health system in Zimbabwe, especially in the
rural areas. This potential necessitates community engagement,
sensitisation to create awareness in communities, empowerment
through skills development and education, and implementation of
solutions and strategies that fit the local context.
(Keywords— eHealth, Masvingo, Zimbabwe)
I. INTRODUCTION
eHealth, we define, is the combined use of electronic
communication and information technologies in the health
sector, ensuring the right health information is provided to the
right person at the right place and time, in a secure, electronic
form for the purpose of optimising the quality and efficiency of
health care delivery (cf. [1]). Among others, eHealth has the
potential of reducing administrative tasks, enhancing quality
and integration of service delivery, lowering of administrative
and financial risks, keeping professionals on site by limiting
travels for training and meetings, and providing for non-
monetary remuneration.
Zimbabwe is in the process of introducing a comprehensive
e-Health strategy. In Zimbabwe, mHealth (mobile health) is
already widely implemented for the strengthening of
communications along the Early Infant Diagnosis result chain.
Application of Data Science to information contained in the
Health Management Information Systems (HMIS) is the next
frontier in disease control. eHealth pilots are highly visible and
provide for encouraging examples of application and beacons
of hope in a depressed health sector. The Ministry focuses on
the gradual rehabilitation of existing and new administrative
and operational systems, possibly leapfrogging into the digital
information era by involving the incorporation of Information
and Communication Technologies.
Based upon its long-term commitment in the health sector
in one of the remote areas of Zimbabwe, upon request by the
Ministry of Health, in corporation with national partners like
Zimbabwe’s Scientific and Industrial Research and
Development Centre (SIRDC), SolidarMed is reviewing how to
play an active role in the exploration of e-Health possibilities
by supporting local infrastructure development, testing of
applications in (remote areas) in Masvingo province, and
strengthening the institutional capacity in eHealth. It does so
from a unique, and long-term base in Masvingo Province.
Therefore, SolidarMed, with its partners, is regarded a long
term partner able to operationalise and test the current and
upcoming innovations in health care, in Zimbabwe, based upon
existing relationships and involvement in support of what
works so far.
Upon this notion, SolidarMed in cooperation with the
Zimbabwean Ministry of Health and Child Care is gearing up
for an e-Health readiness in Masvingo Province. Such readiness
is engendered through developing infrastructure and preparing
for tangible activities in the areas of operation, provisioning of
a conducive environment for (health) community engagement
in eHealth, and preparations to act as pilot/demonstration site.
This paper shows the circumstances and ideas originating
1st International Multi Disciplinary Conference – 23-25 August 2017, Lusaka Zambia
during the initial – sensitisation – phase of eHealth in Masvingo
Province, Zimbabwe.
II. EHEALTH: GOVERNMENTS PERSPECTIVES
African governments recognise Information and
Communication Technologies (ICTs) are instrumental to
leapfrog legacy systems and practices towards improved cost
effectiveness and quality of health care. Since 2011, Kenya
executes a national eHealth strategy “to cope with the rising
cost and demand for quality health care services, against the
backdrop of a shortage of skilled health care professionals. […]
There is […] a compelling need to devise ways and means of
closing the gap between vision and reality. Th[e] e-Health
strategy seeks to set in motion the process of closing this gap
by harnessing ICT for improved healthcare delivery in addition
to other ongoing efforts.” [2:1]. “The [Kenyan] Ministry of
Health is keen to ensure an enabling regulatory environment to
encourage innovation and use of mobile technology in
improving the health of Kenyans. M-Health is one of the pillars
of the Kenya e-health strategy. The other four are telemedicine,
health information system, e- learning and information for
citizens”, and: “One of the most important things M-Health will
deliver to Kenyans is the ability to dramatically improve health
service delivery” [3:online]. The latter endorsement contains a
succinct rationale for eHealth in Kenya.
In Zimbabwe, eHealth is a priority, as the following quotes
from the current Zimbabwe’s National Health Strategy
Zimbabwe (2016-2020) [4], show:
• “The hospital information systems need to be
harmonised and fully computerised with all departments,
equipment and patient flow properly linked electronically.”
(p.50)
• “Significant investments in health system
strengthening are necessary for the health facilities and other
service delivery and coordination platforms to function
optimally. [...] new innovative programmes such as e-health are
implemented to enhance and not to disrupt what has been
working so far” (p.61)
However, much needs to be done, as the same national
health strategy reports: “The item with the lowest availability
was the computer with internet/email access” (p.7).
e-Health bears promise to enhance and integrate health
service delivery, optimise efficiency in health care
provisioning, reduce administrative tasks in health, reduce
traveling and out-of-station period of health staff, and provide
for non-monetary motivation in a depressed health sector.
Zimbabwe‘s National eHealth Strategy is ‘work in progress’.
As the country is coming to grips with the new realities in an
information society, developments still depend largely on
opportunistic networking of people, co-operating partners, and
funding opportunities.
The Ministry of Health currently defined goals focus on the
key tools and applications in health as identified by the
Zimbabwean ministry [5]:
• Telemedicine
• Medical Education and Research Services
• Electronic record systems
To harvest the low hanging fruits in eHealth, Zimbabwe’s
Ministry of Health has embarked on the countrywide role out
of electronic infrastructures to enable an Electronic Health
Record keeping for HIV-related reporting (ePMS) [6]. With
partners, the Ministry of Health is piloting eHealth initiatives to
strengthen maternal and new-born care in Zimbabwe, and the
introduction of telemedicine (e-consultation) in outlying
districts. Further, the Ministry is executing a roadmap towards
a national Electronic Health Registration system [7].
On the provincial level, the Provincial Medical Directorate
Office in Masvingo regards the use of Information and
Communication Technologies of prime importance to attain the
outcomes of the National Health Strategy, including for health
care in the remote areas. Based upon tangible results to make
ICTs accessible in rural Africa [8,9], it aims for community
engagement [10], work force development [11] and thought
leadership [12] for e-Health in the province, for the
sensitization, training and role-out of e-Health pilots,
operational research and other support in the field of eHealth.
III. EHEALTH: COMMUNITY ENGAGEMENT IN MASVINGO
PROVINCE
Masvingo Province consists of a low-veld area, in the south-
eastern part of Zimbabwe. The province covers an area of
56,566 km2 and a population of over 1.4 million people (2012
census) of which around 90% live in rural areas. Most people
in Masvingo’s rural areas sustain their life from subsistence
farming, cattle ranging and from financial transfers –
remittances – from family members in the diaspora.
The Zimbabwean health sector faces human resource
challenges, with challenges for health workers at every service
delivery level. Of course, human resources are critical to the
provision of quality health care. The government recognises
that to address the crisis, it is essential that it ensures an
adequate and equitable distribution of appropriately motivated,
skilled and equitably distributed health workers providing
quality services. Human resource shortages are caused by
several factors which are both monetary and non-monetary.
These include:
• Conditions of service (remuneration and incentives)
• Working conditions (facilities, supplies and
equipment)
• Human resource management systems
• Education and training systems.
There is evidence to suggest that improving amenities and
working environments can help to retain staff [13]. Information
and Communications Technologies (ICT) deployment to
support eHealth and the availability of internet connectivity is
one avenue that could provide for non-monetary incentive to
qualified personnel in the health sector. Preliminary work on
the establishment contextual sound ICT deployments in rural
areas was done at Macha, in the Southern Province of Zambia
[9]. It was shown that access to ICT services could be achieved
through an inclusive process of (1) community engagement, (2)
workforce development, and (3) thought leadership.
1st International Multi Disciplinary Conference – 23-25 August 2017, Lusaka Zambia
Given the promises of eHealth, ICT and Information
Services and Systems can support the government’s agenda
“Equity and Quality in Health: Leaving No One Behind”, which
is the sub-title of the Zimbabwe National Health Strategy
(2016-2020) [4]. The first step to reach this goal is encapsulated
in the process of community engagement. Community
engenders engagement and ‘buy in’, and therefore
sustainability, by involving aspects of a holistic approach, local
empowerment, reciprocity, and enthusiasm [10,14]. Further, it
necessitates action embedded in compassion, desire to engage
with local issues, a learning exchange, stewardship, and the
utilisation and harnessing of local resource, in a sequence of
thinking, practice and progress [14].
IV. E-HEALTH: ENGENDERING INFRASTRUCTURES
In Masvingo, with the use of local skills and resources,
SolidarMed created a so-called eHealth Lab to provide facilities
for the use and development of ICT and services. This is a
facility designed to support the development of contextualised
apps for the rural environment. The lab provides working space
where health professionals and engineers can meet. Hardware
and connectivity are supported, and the facilities are conducive
for improvisation. The laboratory is run by an ICT Officer who
is also available for training.
In the same building, SolidarMed develops a so-called
Future Centre. Here low-cost presentation facilities are being
experimented with involving Communities to Practice.
Through targeted hospital assistance projects, involving
local talent in planning and implementation, SolidarMed
creates sustainable infrastructures (e.g. Local Area Networks at
Hospitals and Nurses Training Schools) while streamlining
operations and equipment, (e.g. thin client computing, tablets
and network servers).
Thin Computing usage at Nurses Training School, Silveira Hospital,
Masvingo Province, Zimbabwe (picture Joseph Bishi)
V. E-HEALTH AND CONTINUOUS PROFESSIONAL EDUCATION
Among others, the Zimbabwe Medical Association (ZIMA)
hosts Continuous Professional Development (CPD) /
Continuous Medical Education (CME) sessions for health
professionals in Zimbabwe, irrespective of their area of
speciality. It is a membership-based association, with about 800
members, whose objective is to protect and advance the
interests of the medical profession in Zimbabwe. One of their
targets is to optimise the environment for a sound doctor-patient
relationship through providing a forum for discussion on
matters of policy and knowledge sharing, and ensuring that
members optimise from practising medicine in Zimbabwe and
protecting the health rights of the public at large. In trying to
encourage evidence based medical practises, ZIMA offers
continuous medical education to its members. The meetings are
a strategic place where health professionals regularly meet for
professional updates and information sharing.
SolidarMed and ZIMA experiment and pilot the
dissemination of CME sessions for remotely attending a ZIMA
meeting of the HIV-clinicians in Harare. In 2016, the first
CME-point from ZIMA was awarded in Masvingo for remote
attendance, with interactions taking place through a live stream
Skype connection between ZIMA Harare and SolidarMed’s
Future Centre in Masvingo. This activity has the potential to
grow in the number of meetings for streaming, boosting
attendance and dissemination of medical professionals, country
wide.
In the current set up, on purpose, low-cost equipment and
services are being used. For the link that shows the presenter,
Skype is used. Presentation slides are photographed on site and
sent through by using WhatsApp. These services are used
because of their general and free availability, readily available
on the personal computers of health professionals. Further,
these services require no special plug-ins to be downloaded,
limiting the strain on the limited bandwidth and throughput of,
often limited, (satellite) internet connections. And, last but not
least, these services are free, instead of incurring extra costs and
the need for downloads, like Cisco’s WebEx service.
Every month, UNICEF hosts a “Brown Bag” sessions in
Harare. The purpose of the lunch meetings is to share
information relevant to health care professionals. The Brown
Bag sessions are led by experts in the different fields who
present findings of contextual research. The meetings are
frequently participated in remotely from Masvingo. These
meetings are streamed through Youtube Live, with the added
capability to access the presentation after the event, in the case
of hickups like power outages during the event.
Attending Brown Bag session at SolidarMed’s Future Centre in
Masvingo, Zimbabwe (picture Janneke van Dijk)
1st International Multi Disciplinary Conference – 23-25 August 2017, Lusaka Zambia
The take up of these CME services is slow. The importance
of experimenting and promoting the facility is necessary to gain
the commitment of all involved in the use of simple, free and
daily used applications. By its use – and the fact that the activity
is ‘being talked about’ – health care professionals are sensitised
to, and experience, how eHealth supports efficient operations.
Efforts have been made in optimising the current setup aiming
for the improvement of infrastructure, ultimately improving
clinical decision making using right solutions in understaffed
and low-resourced environment.
During 2016, from the start with the live streaming of
Brown Bag sessions from UNICEF, the activities have grown
into streaming of webinars, conference sessions (e.g. AIDS
2016), attending meetings in Europe (e.g. on FAIR data), and
even disseminations from Masvingo (e.g. university lectures at
University of Cape Town and in Europe).
VI. EHEALTH AND REMITTANCES/MOBILE MONEY
In the developments of mPesa (mobile money) and eHealth,
Kenya is an example on the African continent. In Kenya “...
approximately 53 percent of the country’s GDP was transacted
through mobile money platforms. ...” [15:online]. A dignitary
of Kenya’s government commented “through the efforts of
inclusive business models which aim to include the poor in their
value chains, we have seen an emergence of a wide spectrum of
services for those at the bottom of the economic pyramid with
services ranging from accessible health insurance to primary
healthcare services, facilitated by technology and especially
mobile platforms” [3:online]. Our exploratory research
suggests that the condition in Zimbabwe is not much different,
and what happened in Kenya might very well happen in
Zimbabwe.
Picture is showing “taxi” in South Africa with a message to remit from
South Africa to Zimbabwe (2016, Gertjan van Stam).
The benefits ‘at the Bottom of the Pyramid’ can be
“increased access to quality healthcare, such as through mobile
money-based e-vouchers that are only redeemable at accredited
healthcare facilities; safe and convenient platforms for
mobilizing funds to pay for healthcare products and services;
increased opportunities to save for future healthcare needs; and
increased access to affordable health insurance. Mobile money
has also provided development partners with a means to directly
channel funds to targeted beneficiaries” [16:np]. These benefits
are all potential innovations for Masvingo.
eHealth involvement of the business sector embedded in the
formal economy seems to focus on the urban areas [17]. In the
mean time, the hospitals in remote locations are prone to benefit
most, but receive last, in the case of an external/urban focus on
remittances. Building capacity in peripheral institutes is most
urgent and can provide for ‘a way out’ of the current financial
conundrum of diminishing incomes at the rural hospitals.
In Zimbabwe, mobile money is used by the Health Center
Management Funds. These small scale community funds are
coordinated by village heads and councillors. Experts report
that in Masvingo these funds receive most of their contributions
through EcoCash. The Health Centre Management Funds had
various roles, among them, being supporting the most
disadvantaged with out-of-pocket-user fees, renovating staff
houses, waiting mother’s shelters, and patient waiting areas,
paying for the night security guard and general hand.
The government of Zimbabwe recognises the importance of
remittances, and focuses on its leverage through the newly set
up National Diaspora Directorate for purposes of encouraging
the people in the diaspora to participate ‘in the country's
economic turnaround strategy’.
VII. EHEALTH AND APPLICATIONS
From its experience in community engagement, SolidarMed
has noted that investments in infrastructure development
remain the priority at the health institutes. Without
infrastructure, service provisioning is not possible. Upon the
existence of infrastructure, with partners, Solidarmed has
started the sensitisation in applications development, focusing
on applications in the following fields:
• Mental Health: SolidarMed participates in the
development of a ‘Friendship Bench App’ for Mental
Health.
• Interaction by Health Professional: experimenting with
VULA App for physician peer-to-peer communications
and referrals.
• Clinical Mentoring Tool App: Aiming to enhance
operations and management of Clinical Mentoring in a
decentralising health care service provisioning, and
• Electronic Health Registration: Preparing for the
Governments Electronic Health Register
Implementation.
VIII. CONCLUSION
eHealth holds significant promises for the health sector in
Zimbabwe. Due to the virtual non-existence of services aimed
at rural areas, there are opportunities to unconstrained
‘leapfrog’ into eHealth. Zimbabwe’s government guides
eHealth deployment in careful wording, for it ‘to support what
is going well’. eHealth opens contextual opportunities that
could alleviate pressing problems, for instance in facilitating
out-of-pocket expenses through mobile money and remittances.
The process of Community Engagement for eHealth
involves sensitising the process of assisting institutes in
1st International Multi Disciplinary Conference – 23-25 August 2017, Lusaka Zambia
building up eHealth infrastructures, in the engagement in
application development in line with opportunities applicable
for the province, and by strengthening the eHealth knowledge
base and capabilities.
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