Bridging the Digital Divide in Health

With these words, United Nations Secretary-General Kofi Annan captured the promise of information and communication technologies (ICT) in his opening address to the World Summit on the Information Society in 2003. Building on the Millennium Development Goals (MDGs), this compelling vision opened the door to new commitment, new investment and, most of all, to creativity and the drive to push the boundaries of technology far beyond anything ever dreamed. Today, it is thanks to those pioneers determined to experiment with new technologies in new settings -- often challenging and risky -- that many can take for granted the benefits that ICT brings to health. For too many others, that promise is still unfulfilled.

A fundamental change in the years since the MDGs were agreed upon is the appreciation of the role that ICT can play in meeting health targets. It was not so long ago that health decision makers were questioning the utility of adopting ICT in health services and systems -- that is, "e-Health" -- particularly in developing countries. At that time, e-health projects were few in number, disconnected, small, and costly. They were driven not by countries, but by funders. Their planning and implementation usually relied on technical assistance provided by aid agencies and the international private sector, as there was little local expertise to draw on. The aim of these initiatives was most often technology proof-of-concept or exploration of new markets, rather than strengthening local health care processes. Not surprisingly, decision-makers remained unconvinced of the value of ICT for health as projects distracted staff from regular duties, applications and infrastructure were unsuitable and unreliable, and in the end there was no definitive way to measure the impact on health outcomes.

Nor was there a consensus on priorities for investment. Some may remember the energetic debate as to whether development aid should be spent on computers or vaccines -- a debate that goes on to this day. Particularly in the poorest countries where daily survival is the goal for a large part of the population, it can be hard to justify any expenditure beyond meeting basic human needs. The debate was also fuelled in part by high-profile initiatives that, while breaking new ground, were nonetheless unsustainable and therefore used as examples of the failure of technology in these settings. However even in richer countries the value of ICT in health has been easily dismissed by skeptics who have forcefully and successfully argued that scarce funds were better invested elsewhere.

Today ICT in health is not so easy to dismiss. Over the past ten years, the paradigm has shifted as the use of technology has gone from unimaginable to indispensable in many sectors. ICT has diffused throughout the world, reaching even to remote regions and transforming global commerce, entertainment, and industry. As the use of e-health grows, it is anticipated that new businesses will emerge and economic opportunities will proliferate along with platforms for innovation and services. In countries with established e-health markets, more efficient, effective, and personalized care is becoming an important objective, and citizens actively use and share information to obtain better services, prices, and treatment.

ICT has, for years, been promoted as a driver of development and markets and, despite significant gaps in access to ICT that still remain, country statistics bear that out. Although health has long been promoted as a beneficiary of ICT and there have been significant gains in its adoption, it is clear that the digital divide remains both within and between countries. It was not until recently that figures on the use of ICT in health in countries became available, through the World Health Organization's (WHO) Global Observatory for e-health.1 The most recent report in 2010 shows that adoption of ICT in the health sector is growing steadily and that there is a groundswell of activity in emerging areas such as mobile health. It further shows a distinct gap between rich and poor countries, not simply in the types and volume of e-health activity undertaken, but also in terms of awareness of the benefits that e-health can offer. There is not yet a strong evidence base for e-health, without which the case for more strategic and widespread investment cannot be made.

Taken together, the WHO global e-health surveys, case studies, and a decade of experience in e-health in countries has been instructive. What have we learned?

Lesson 1: Connectivity. It is not only feasible, it is also essential to provide access to communications and ICT tools, even in remote settings. Inadequate infrastructure and basic services such as electricity and telephone present a major challenge to achieving the connections that health centres need for their daily activities. Ultimately, the solution lies in working with other sectors in order to establish the ICT infrastructure that can be used and shared for health. Mobile technologies are a significant step in this direction, and their broad and rapid uptake has irrevocably changed the concept of access.

Lesson 2: Content. Access to health information and knowledge resources is vital for health care and public health, and is an important motivator for ICT use. For health professionals, critical content includes health resource collections, programme and policy documents, statistics, scientific publications, and tools for research and clinical practice. Health information is empowering for citizens, facilitating choice and transparency. Enabling access to reliable, relevant, affordable, and high-quality information on health, in appropriate languages, should be a high priority for governments.

Lesson 3: Capacity. Access to information and the capacity to use it go hand-in-hand. Effective use of ICT in public health and health care requires specific skills. Training and education open the door to the information society and this investment in tomorrow must start today. Without this capacity, the potential of ICT in health cannot be met in any setting.

Lesson 4: Context. Coordinating efforts, identifying priorities for investment, ensuring equity, and optimizing use of limited resources requires pro-active policymaking with the aim that citizens, health professionals, and the entire health sector benefit. E-health innovations cannot go far and adoption cannot occur without investment in infrastructure, education, policies and services to ensure equitable and affordable access to ICT for health. National policies must be shored up where needed to meet the challenges of the information age.

Most countries are now moving forward in e-health, with innovative partnerships playing a catalytic role. Whether to deliver care to individuals, intervene for the health of populations, pursue research, or educate professionals, the use of ICT in health is gaining momentum. The information society is the central reality of our time and we must help others build their future within it. We know it will take time, resources, and political will. Most of all, we know that there is no turning back.