Signs of a Growing eHealth Sector in Kenya

Today I had this nice opportunity to partially attend a PEPFAR partners meeting at the Safari Park Hotel. I shall not assume it is obvious that PEPFAR stands for (United States) President's Emergency Plan for AIDS Relief. Kenya is said to be one of the countries with the biggest allocation of PEPFAR grants, largely through USAID and CDC. Every year, billions of Kenya Shillings are handled as grants from PEPFAR within the country, so much so that it is almost a sub-economy in itself. PEPFAR, essentially the philanthropy of the American People appears so immense in the health sector that the aid should ideally overflow to the ICT sector through eHealth. For more on related development dynamics see my earlier post on who really are our genuine development partners.

Over time, PEPFAR leadership may have discovered that it is not possible to practice philanthropy in the air - it has to be in someone's jurisdiction -  who needs to care that they Americans are being philanthropic. Although the partners meeting I attended was full of representatives of NGOs supported by PEPFAR, it struck me how the agenda and presentations had undertones of leadership and control by the government. It was also impressive to see the relatively young and professional representation from the government.

Perhaps some readers will frown or cringe at the thought of government stewardship of the eHealth agenda. Consider the scenario where donor funded NGOs have to use this nice MS Access Application developed by this wonderful self taught American Programmer. That would be a self made 'geek' sitting at some place in the US offering great support and maintenance whenever MS Access bugs crop up or whenever the dismal functionality MS Access must be pushed to some impossible limits. Of course once in a while there is also a need for them to offer support on matters like 'which Microsoft Office 2003 service pack to install' and so on. You might also say that I am not the greatest fun of Microsoft products or proprietary systems. However Kenya is a country with quite a wealth of job seeking, highly skilled, economically frustrated software developers - some of them quite accomplished. The picture appears wrong for huge sums of donor aid to a country with jobless software software developers having  their 'donor aid' monitored through what might appears to be a makeshift MS Access application managed overseas.

The above picture has been possible because the government of Kenya and its economic sectors have not been keen enough to take full ownership of the aid given to the country. However, the increasing government stewardship of the eHealth agenda in Kenya promises to help in ensuring that its people and its economic sectors directly benefit from the very aid that donor initiatives purport to give. It might be fair enough for donor money to bounce back to its origin through purchase of anti-retro-viral drugs, bed nets,  condoms, computers and mobile phones. However, it appears unfair for the aid to dodge our fledgling software development talent, bouncing back through the so-called technical assistance expenses like developing and supporting an MS Access application.

During the meeting which had a lot of eHealth talk, I was particularly impressed by presentations delivered by government officials. The presentations outlined progress made and planned initiatives around eHealth which included :-
  1. A presentation of plans to rollout a District Health Information System to replace the existing MS Excel Based FTP site for health facility reporting - I gladly observed a silent drift towards DHIS2 - an open source platform that could challenge the use of  the KePMS system. A proposed overall initial implementation budget of Ksh 54M appeared realistic to me (peanuts for donors).
  2. A presentation and demonstration of  the Community Based Program Activity Reporting (COBPAR) system - developed in-house at the National AIDS Control Council on an Open Source Platform (currently only available through their VPN).
  3. A presentation on the almost ready standards for EMR systems in the country (with functional/ interoperability profiles and guidelines for implementation and human resource capacity building). Government seems to have seen the sense that it only needs to encourage an environment of efficient interoperability - away from an earlier drift to push for a default national EMR system (read controversial).
  4.  A clarification that the division of Health Information Systems is pursuing ideas around building an enterprise architecture (EA) for systems in the the health sector - see my earlier post on the importance of EA
  5. Some profound thoughts on NASCOP's strategy for HIV/AIDS and STI disease surveillance (to be supported by eHealth sub-systems)
One might say that success of eHealth initiatives is a default expectation and that 'government can only be interfering'. I would disagree and see the important role of government in  providing the conducive environment for eHealth systems flourishing and efficiently co-existing. Government involvement is also a sure way of ensuring that eHealth initiatives are efficiently tapping from our donor generosity. If the current trend is upheld and protected from adverse political changes, eHealth initiatives including OpenMRS, DHIS2, Child Count, iDart, Jacaranda Health , FrontlineSMS:medic and others are destined for success in Kenya.

Part 2 of Insights from the 5th Annual OpenMRS Meeting

A couple of days back I wrote my first article on the  the fifth annual OpenMRS implementers meeting. Immediately after posting the article I checked my meeting notes and thought I would need to write on a few more insights that appeared equally profound. Consider this a continuation of the lessons I described in the earlier post.

Lesson 4. Open source is great; best with a global community
One of the big debates in many developing countries is whether to adopt an Open Source policy for their e-government initiatives. It appears key decision makers have began to appreciate the benefits of such a policy. However there needs to be further understanding that a mere application of open source technologies for development of government software systems is not enough. There is need to embrace the concept of open source from a global community perspective.  A software expert or two can sit with an health care expert and develop an awesome, robust, feature-rich EMR or Pharmacy system using open source technologies. The system can easily go ahead and be deployed successfully in a health facility or two. The challenge with such an awesome system would revolve around the nature and size of its community of implementers and developers. Such challenges would begin to show when it begins to expand its scope, both in terms of number of installations and scalability of functionality.

During the meeting I confirmed the unparalleled size and diversity of  the OpenMRS community - for an EMR sytem. However, the bigger learning point for me was that indeed a large and diverse community enhances chances of software supporting global best practices.  I may not be placed best to comment on this a the medical or health care point of view. However description of the whole idea of OpenMRS concept collaborative (OCC) and meta-data sharing had strong indications of how powerfully the open source, multi-institution approach can influence harmonization of terminology and adoption of best practices in the health care domain. Dr. Andy Kanter’s presentation did very well to highlight the possibilities and potential around concept sharing.

From the information systems point of view, global best practices on software design and development were an underlying feature of the technical discussions - as a necessity. In this era of globalisation, I was particularly impressed by the approaches to providing services in resource-constrained environments. These I thought in due course can be perfected by developing countries and competitively propagated to developed country settings on relatively  less resource-rich but essential devices like mobile phones.

In general my lesson here was that an open source system built and maintained by a small or closed community can be as inflexible and as expensive as a proprietary system. Any open source software initiative with a national or global ambition should strive to build a large community enough to sustain its growth objectives.

Lesson 5: Enterprise Architecture optimizes on resource use and unifies efforts
During one of those parallel tracks at the meeting there was this intense debate about Enterprise Architecture (EA) and OpenMRS. On my part I had long held this belief that EA was too abstract a concept to be directly relevant to a national health information systems arena. More so for a low-resource, developing country setting, the concept had unfortunately appeared to be ‘too high up there’. The turning point for me was when a participant dared the rest of us to think that “Perhaps EA is NOT too esoteric to be talking about in a low resource setting”. Of course I had to first struggle through the definition of the enterprise itself - noting that the enterprise could be ‘Myself’, a clinic, a Ministry of Health Division, A country’s health sector, or even a countrywide ‘all sectors’ as an entity.

Incidentally I got convinced during this session that a country having EA is one of the biggest success factors for achieving an effective implementation of a nationwide eHealth systems. The simplest benefit of an EA seemed to be its ability to harmonise terminology across the eHealth landscape. For instance it would reduce misunderstandings arising from the lack of a distinction between roles of constituent components such as the EMR, the HMIS system, the Supply chain management system, the Communuty Health Worker system and so on. Where there are many stakeholders, EAs assists every contributor to the national enterprise architecture to focus efforts on the functional and interoperability profiles of envisaged components. Such critical understanding has immense potential to reduce duplication of efforts and wastage of expensive donor money in the developing world.

Furthermore, with EA’s ability to unify national stakeholders around technically sound functional and interoperability profiles, it was regarded in the discussions as an important cushion if not a weapon against the ever looming adverse political changes in our health ministries.

There were endless lessons and insights in the meeting and you might guess I still have a couple of more thoughts worth writing about. I shall leave that for yet another blog post.

Insights from the 5th annual OpenMRS meeting

Last week I had this great opportunity to be a participant at the fifth annual OpenMRS implementers meeting in Cape Town. The meeting brought together implementers, developers and the leadership of OpenMRS. The meeting was of the  'unconference' style and being relatively less experienced with OpenMRS,  I found myself simply following through the intense sessions, soaking up a lot of knowledge and insights. There were many lessons and great experiences including ideas on how to actualize the dream in my earlier post on adopting OpenMRS in Kenya. I shall try and describe three of them in this post - based on my personal synthesis.

Lesson 1: Clinical Systems Not Reporting Systems

During one of the evening discussions with Dr. Alvin Marcelo and a few others round a dinner table, I had this bulb light somewhere in my mind that 'Really, medical record systems need not be seen as reporting tools'. In fact, to some health care practitioners, that the medical records system assists in retrieving a patient's medical history and perhaps assists in diagnosis is all that should be expected of the system. To them, other information management issues including aggregation of patient and treatment statistics for what we know as monitoring and evaluation - (read reporting) is almost out of scope for a medical records system. The idea that an EMR system needs to primarily address the health care givers' information requirements at their points of care implies that national Monitoring and Evaluation (M&E) and reporting needs become secondary in an EMR. These observations got me thinking that perhaps the efforts to have electronic medical records systems (EMR) in Kenya will not necessarily yield the desired expectations. In Kenya, the National STI and AIDS control program (NASCOP) and the division of Health Information Systems (HIS) in the Ministry of Public Health and Sanitation have over the last couple of years been working hard towards having elaborate EMR systems used at the country's public health facilities.  With the  country's drive for implementation of EMR systems being 'national reporting', it appears NASCOP and the division of HIS might be better off concentrating efforts on district health information systems such as DHIS2. It should be possible to allow for diverse EMR systems that support the SDMX-HD protocol for data exchange with the DHIS system to facilitate upward aggregation of data - hence national reporting. This of-course is not to disregard the need to foster data use and M&E at the administrative level of health facilities.

Lesson 2: Symbiotic Relationships Paramount
It is fairly easy for health experts to say that the field of health information systems (eg medical record systems) is their exclusive domain. Such a perspective can be 'legitimized' by many valid arguments to the extent that the relevance of input from other professions can be seriously downplayed.  Conversely, from a different perspective, information systems experts can easily 'justify' why health information systems is their domain. When these perspectives are not adequately reconciled, there exists a high probability that in an health information systems implementation, either the health or the information systems aspects will fail to be optimized on. During the meeting, several participants emphasized that the development and implementation of successful medical records system calls for a symbiotic relationship between health care professionals and IT professionals. Moreover, health information systems implementation require meaningful engagement of all would-be beneficiaries. This was well summarized in Chris Bailey's observation that "if you want the truth about an Electronic Health Records system implementation, talk to the nurse"

Lesson 3: Who and What really is OpenMRS?

Am sure this is a lingering question in most readers' minds.  To me the question was answered better during the meeting. A plenary session with Dr. Paul Biondich helped to understand the idea that OpenMRS is both a global community and a software platform. It is a non-profit, multi-institution collaborative. Its mission is to improve health care delivery in resource-constrained environments by coordinating a global community that creates a robust, scalable, user driven, open source medical records system platform. From a different perspective, OpenMRS is also a software platform and a reference application which enables design of a customized medical records system. One more related learning point was that there was an on-going undertaking to incorporate a non-profit organization that would facilitate a more proactive pursuit of the community's mission.

In general there was a sense that for a health information systems initiative like OpenMRS, maintaining a balance between meeting health care delivery and software evolution objectives is paramount. Some nice photos of the meeting can be found here as posted by John Wesonga

Local content grants: Government information portal awards to firms first

This week there was much buzz about the Kenya 2009 census results, the on-going contest among our mobile networks, and other developments in the Kenyan online content space. What may have passed some of us in the midst of the noise is the announcement of one category of winners for the first round of Local Content and Software Applications Grant. As earlier mentioned on this blog, the initial processes of the grant had a number of useful insights if the ICT Board's post-application survey was to go by.

Applicants for the grant in the government information portal / firms category were announced on 31st August 2010. In this category, seven proposals were chosen from a list of 166 proposals by firms according to the ICT Board's press statement. The seven proposals were
  1. Octopus Solutions Limited - HIV and AIDS in the workplace e-Learing Course - To assist implementation of the HIV and AIDS work place policy among civil servants
  2. Infotrack Strategic Solutions Ltd - Teacher's Portal - Linking Kenyan teachers with their employer (The Teachers Service Commission)
  3.  iBid Labs - Kenya Online Museum  - Multimedia documentation of Kenya's rich history
  4. Foundation Support Services (FSS) Ltd - IVR Tax Filing Solution - A multilingual platform for Kenyans to file tax returns based on Interactive Voice Response (IVR) technology
  5. BTI Millman Company Ltd - eMazingira Software Application - Crowd sourcing application for documenting and collecting information on environmental degradation and abuse using the Ushahidi platform
  6. RiverCross Technologies Ltd - EDUWEB- To create a comprehensive list and interactive map of all education institutions in Kenya
  7. JBA Advertising Co Ltd  - Lost and Found Project - To assist Kenyans to find their lost official documents such as national ID cards 
Needless to say, successful implementation of the above proposals alone is bound to make a huge impact  to Kenyans, solving some of their most basic problems.  The proposed projects also have potential for fostering a productive online culture and the growth of our knowledge economy.

It is noteworthy that the ICT board did not announce winners for the other grant categories a per the schedule earlier promised. The missed target is definitely a disappointment for many stakeholders watching - in Kenya any unexpected / unexplained delays in such a process can result in all sorts of conspiracy theories. Nevertheless the board was kind enough to make public more finer details about the remaining categories and the number of applicants as follows :-
  • Category A: Individuals - Private Sector Digital Content and Software Applications Grants - 133 applicants
  • Category B: Firms - Private Sector Digital Content and Software Applications Grants - 256 applicants
  • Category C: Individuals - Government Information Portal - 112 applicants
The board went further to promise announcement of the successful grantees for remaining categories on 28th September 2010. With the earlier missed targets for announcement of  evaluation results, it remains doubtful that the new target can be achieved. The doubt remains considering that the first category results announced so far cover barely a quarter of the entire round's applications.

Videos related to the ICT board's announcement at the Serena Hotel can be found here