Global review on Access to Health Information in Developing Countries
British Medical Association on Monday, 12th July 2004.

Making health workers in Africa part of the global information society: achievements and lessons learned in the last decade

F. Bukachi, MD, PhD
Research Fellow in Cardiovascular Medicine
Norrlands University Hospital, Umeå, Sweden

The last decade witnessed a rapid and profound change in the Internet landscape on the African continent. All health workers, especially those working with isolated communities, welcomed this change. To them, this technologic revolution promised an end to both professional isolation and information poverty, and therefore it could not have come at any better time. Prior to 1990, a letter from East to West Africa took no less than 3-12 months to arrive; the cost a five minute telephone conversation between colleagues in Africa was more than a monthly income of a university professor; and faced with oppressive external debt burden, virtually all libraries in medical schools in Africa, with the exception of the Republic of South Africa (RSA), had discontinued subscription to international journals and relied only on token donations from partner libraries in Europe and North America. The arrival of the Internet, therefore, heralded a new beginning, which heightened expectations, renewed optimism and rekindled hope. 

By the year 2002, direct Internet access was present in all capital cities in Africa, serving a total of 7-8 million users out of the continent's estimated population of 816 million. Good news as it may sound, this accounted for only less than 1% of all the global Internet traffic, and 80% of this traffic came from one country - the RSA. Presently the number of Internet users in health sector remains unknown. However, based on previous estimates this could be placed at less than 0.1% of the total user population in Africa. In addition, this privileged group is almost entirely located in urban centres leaving the rest of the rural-based health workers who serve over 75% of Africa's population without any meaningful access. This reminds us that the digital divide is not only between countries and regions but also within countries - a critical issue for those concerned with dissemination of health information. 

How can we 'fast-forward' to the future? Ten years ago, the technology sector promised that the wireless (mobile) technology would propel Africa into the digital global village. This promise was made on a background of poorly maintained, state-owned landline telephone networks that could not support high-speed modems and were often damaged by rain, theft or vandalism. Furthermore, the number of people waiting for a new telephone connection was growing every year and the waiting time had reached an astonishing average of ten years in many countries. In response to mounting pressure from donor countries in the West, most African governments privatised these non-performing corporations and invited foreign investors to take over. Indeed, mobile voice telephony became available and is now widespread and signals can be detected in any village anytime, anywhere in Africa. It is now estimated that 1 in every 35 Africans has a mobile telephone phone compared to 1 in 40 for fixed lines. Although the growth of mobile technology has been phenomenal in the region, it has potential tragic consequences for health sector if it continues with its current approach to service provision. The movers of this new technology, intentionally or otherwise, separated communications from information access, the two most fundamental attributes that define a successful network. Subscribers, therefore, have a communications network devoid of information component. This action highlights that 'fast-forward' to the future within health sector context in Africa and other developing parts of the world will not depend on the availability of cutting-edge technology alone, but rather on its appropriateness. 

The grim coin, however, has a successful and hopeful side to it. Within a few years of introducing Internet to health sector in Africa, the number of subscribers grew exponentially. Thanks to SatelLife for its early pioneering work through HealthNet, its global telecommunications network. The rapid growth in subscriber base could, in retrospect, be attributed to a number of reasons. First, and perhaps more obvious, was the urgent need for an efficient communications network to complement or replace a failed postal service. Second, the information package and electronic conferences provided through HealthNet, to some extent, filled the yawning void created in medical school libraries. Third, HealthNet employed a technology that was efficient, cost-effective, and well suited to the prevailing conditions at that time. Fourth, HealthNet played the golden ABC rule. It spread Awareness, replicated Best practices and created user Champions. The net outcome of all these activities was the improvement in local information and communication technology (ICT) policies. Further, tariffs on the importation of computer hardware were abolished in a number of countries in Africa, thus making more computers available in health sector. More importantly, training health workers on how to use basic e-mail services improved their computer literacy. Interestingly, some doctors used a computer for the very first time during these training sessions.

Success could not have been achieved without partnerships between donors, Southern and Northern non-governmental organisations, and grass-roots users in Africa. This relationship was so pivotal in the growth of the Internet in health sector that several lessons were learned. For instance, SatelLife harnessed local knowledge and synthesized it with international experience creating a formidable self-propelling ripple effect across Africa and Asia. This was its secret to success. Partnerships which help empower people on both sides of the equation, and which utilise technology to bridge the divide between those with resources and those without tend to survive the test of time. Satellife's failure, however, was its inability to create sustainable user groups that also had a sense of ownership of local programmes. Moreover, the organisation's role in Africa was defined more by its technology than its services. An important lesson for those creating a virtual library is that, by placing partnership before a specific technology or a specific solution, allows users themselves to create their own futures. Creating one's own future gives them a sense of ownership. African medical journals therefore must be supported to publish local research and contribute to the virtual library. This is, perhaps, the only way African health workers will feel truly part of the global information society.

Finally, like any revolution there are usually winners, losers and inevitably casualties. Despite the prevailing hostile environment towards Internet growth in Africa, commercial service providers emerged winners while the health sector failed to fulfil its expectations. Moreover, hundreds of health workers together with millions of their patients who reside in the rural countryside remained alienated by a technology that was largely driven by financial gain than the desire for universal access. Unless this disparity in access is carefully addressed, a large proportion of health workers battling at the frontline of the world's major public health problems will remain excluded. Reaching this group at the 'last mile' will determine whether global health information access can be achieved by the year 2015.

Acknowledgement
Mike Jensen for providing some of the statistics <http://www3.sn.apc.org/africa/>