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The Health InterNetwork
A Health Information Forum meeting held at the British Medical Association, Tavistock Square, London, WC1H 9JR, Tuesday 17 July 2001
Chair: Prof. ANDY HAINES (Dean, London School of Hygiene and Tropical Medicine)
Contents:
1. 'The Health Internetwork' - Joan Dzenowagis, Project Manager, Health Internetwork, World Health Organization
2. 'The Health Internetwork: Response from the perspective of a medical librarian working in a developing country' - Helga Patrikios, Medical Librarian, University Of Zimbabwe
3. General Discussion
1. 'THE HEALTH INTERNETWORK' - JOAN DZENOWAGIS, PROJECT MANAGER, HEALTH INTERNETWORK, WORLD HEALTH ORGANIZATION
The Health InterNetwork (HIN) is a WHO-led UN project announced by Kofi Annan, Secretary-Gerneral of the United Nations, in his Millennium Report in March 2000.
GOALS
1. Improve global public health by facilitating the flow of health information worldwide, using Internet technologies.
2. Enable more effective health service delivery through (1) access to high quality, relevant and timely information; and (2) better communication within the public health community.
CONCEPT
- Content: provided through an Internet portal
- Connectivity: at selected information access points in countries
- Capacity: skills development for public health information access, management and use.
END-USERS: health service providers; researchers and scientists; and policy makers at all levels.
PARTNERS: UN agencies, governments, non-governmental organizations, foundations, private sector, collaborating institutions, universities and health centers.
ROLES OF PARTNERS
- WHO will provide coordination, content development, strategy and evaluation.
Government and private partners will provide concept development, implementation and evaluation.
- UNICEF, UNPA, and other UN agencies will provide implementation and evaluation.
- Technology partners will provide portal development and content publishing.
- UNDP and ITU will provide connectivity and support.
- NGOs and foundations will provide resources and logistics support.
GUIDING PRINCIPLES
- Partner orientation non-profit, non-commercial
- Separation from business goals and interests
- Inclusiveness: local, national and international partners; public and private
- High standards for quality and ethics
- Equity and affordability.
IMPLEMENTATION
6-12 month planning and development
1 year pilot operation and evaluation
5 year expansion to broader scale.
PORTAL
Health InterNetwork will provide a portal to statistical data; scientific publications; information collections; IT health applications; and training and courses. Users will be able to navigate or search, customize the site to their own requirements, and communicate with one another. The user interface will center on reference and training; and public health policy and practice.
CONTENT SELECTION
A Global Content Advisory Group will set selection processes and criteria, and define content scope and providers. National Content Advisory Group will apply global criteria and processes to local content, and will select local content and providers.
GOVERNANCE
The Health InterNetwork is being implemented by an Implementation Task Force responsible to a Steering Committee.
PILOT PROJECT SELECTION CRITERIA
- Established public health project or program
- Possible to establish pilot in 6 months
- Potential to measure outcomes
- Addresses broad user spectrum (across the pilots)
- Expressed interest and commitment in country
- Relevant to WHO public health priority area
- Potential for contribution to global public health community through HIN.
The development of each pilot project is based on a needs assessment:
- User information and communication needs
- Public health content inventories
- Connectivity assessments (hardware, telecom, logistics)
- Analyses of public health information environments.
HIN RESEARCH NETWORK PILOT
This involves health researchers in 9 WHO Collaborating Centres, in Africa, Eastern Europe, Central Asia. The aim is to facilitate integration of essential local research into global research community, and provide equitable access to biomedical information. This is being achieved through the formation of strategic partnerships with major international publishers, and the OSI/Soros Foundation network
ACCESS TO RESEARCH INITIATIVE
Six publishers are providing over 1000 journals to countries via tiered pricing (free or low cost): Blackwell, Elsevier Science, Harcourt Worldwide STM Group, Springer-Verlag, Wolters Kluwer International Health and Science, and John Wiley.
The aim is to make these journals available and affordable to academic and research institutions in 100 countries. Country eligibility is based on GNP per capita.
The Access to Research Initiative will be launched in January 2002 and will last 3 to 5 years in the first instance. WHO will provide user authentication through a HIN portal, and OSI will provide consortia assistance, content packages and pilot support. Connectivity and training will be critical for researchers to benefit fully.
For further information, please contact Joan Dzenowagis, HIN Project Manager, at
<[email protected]>
2. 'THE HEALTH INTERNETWORK: RESPONSE FROM THE PERSPECTIVE OF A MEDICAL LIBRARIAN WORKING IN A DEVELOPING COUNTRY' - HELGA PATRIKIOS, MEDICAL LIBRARIAN, UNIVERSITY OF ZIMBABWE
Congratulations to all those who have had the vision to introduce the concept and initiate the reality of a Health InterNetwork (HIN) - and who are now acting decisively to bring Health Information high up on the political agenda of relevant international organisations.
I have been working in a medical library in a low income country, Zimbabwe, for 23 years. The University's Medical library in Harare is responsible not only to the Medical School, but also to any and all of up to 13 000 health professionals in Zimbabwe. The prospect of a Health InterNetwork is of immediate significance to us.
Joan Dzenowagis' picture of the Health InterNetwork's achievements, its structures and principles and its plans for the future, is tremendously encouraging - we are seeing the launch of a systematic, multi-sectoral and multi-level attack on the growing digital divide, with Internet and ICTs as both medium and message.
Unquestionably, access to the resources of the Web - its databases, its range of reference sources and now the greatly increased list of free electronic journals - these must hugely improve the decision-making capacity of public health experts. The Internet has become essential for effective and efficient research and development activities.
Obtaining and maintaining ITs and access to the Internet has consumed a lot of our time; justifiably, because IT services - CD-ROM workstations, e-mail and some (too little) access to the Internet - compensate to a great extent for our lack of current books and journals. Like HIN, we in Zimbabwe regard our three main priorities as Connectivity, Content, and Training.
These priorities might relate well to the three main considerations when looking for a new house. As estate agents insist, these are location, location and location. For researchers and other specialists and educators, the agreement last week between leading publishers of academic journals will be a milestone of progress in bridging the digital divide - for the fortunate minority in central locations in Zimbabwe and other poor countries.
Our equally great concern, however, is with those 13 000 health care providers, outside our cities, and with students throughout Zimbabwe, who now have little or no access to relevant information in any form, let alone the Internet.
CONNECTIVITY
In most rural health centres in Africa access to information in any form is the same as it was before ICTs. A survey last year of information priorities and needs of doctors and clinical officers in district hospitals in Zimbabwe shows they are about the same as those of a 1984 survey - the average 'library' of 20 aged books and two current journals would be representative of the situation in many countries.
What difference has the arrival of ICTs made in outlying hospitals and clinics? In recent years donors have funded the installation of PCs, with email and Internet access in hospitals with reasonable telephone lines. Our survey found that these are used by a minority of hospital staff, and infrequently.
Rural and urban users in Zimbabwe and neighbouring countries complain of the frustrations of narrow bandwidths and congestion on the Internet. We know too well what it's like to wait half an hour for one page to trickle down like treacle onto the monitor. Internet access of that quality is bad for the health.
CONTENT
Many of us query the relevance of the information on the Web to the needs of healthcare providers in low-income countries.
It is well known that clinicians in industrialised countries are frustrated when urgently seeking specific data for patient care. Here is a comment from an American physician:
"long sessions spent browsing interesting links on an unfamiliar topic are still mostly done at home" But, she continues,"Work demands simple answers to specific questions - accurate, complete and delivered instantaneously".
"She" is a medical doctor writing to the New York Times, and she reflects the frustration of many doctors in not finding on the Web specific answers to specific questions - even where working conditions are at their best. This shortcoming is one which the Health Internetwork may be able to help remedy, in its portal, by providing levels of clinical information relevant for both low-income and industrialised countries.
TRAINING
Part of this American doctor's trouble may have been a lack of training or guidance in Internet use. In George Washington University's medical library recently, librarians told me of the great success and popularity of an outreach programme to train staff in local hospitals how to find the detailed specific information they needed - they were helpless in the face of the volume and variety of information available. Training in basic computer skills and reaching the best electronic sources will be as important in the long run as connectivity. Training in ICTs must be incorporated into the curricula of schools of health sciences which can achieve a degree of connectivity.
Meanwhile the reality is that without greatly improved telephone lines or sustainable satellite connections, and multiple access points in all health facilities, Connectivity will remain sadly limited by Location, and ICTs will make little impact on the sense of information isolation and disadvantage which our front-line health-workers still experience.
These are the doctors and nurses throughout the continent who care for the huge numbers of Africa's sick - in urban, provincial and rural hospitals and clinics, under conditions and financial constraints which would be unthinkable in the industrialised countries. These doctors, nurses, pharmacists and environmental officers are surely the most important end-users for health information.
In Zimbabwe we want to prioritize the dissemination of CME and reference materials for front-line health workers. We want them to have their own collections of ring-bound clinical guidelines and protocols etc. Those who have no electronic sources at all must be able to receive and request the information they need to be sent to them, down the electronic-print chain through the 'Relay stations' or 'Staging Posts' proposed in recent months by various HIF participants. The last lap of the relay will be run with old-fashioned print.
To ensure that each health worker has the reference material he or she needs we'd like to see all health workers armed with their own private portable libraries - a ring-binder file which will contain a compilation of therapeutic guidelines, protocols, updates - the basic information which is essential for them to practise confidently and well.
We are left with four questions:
1. Is there a risk that the activities of the Health Internetwork could be technology-driven rather than demand-driven?
2. Will HIN be able to respond comprehensively to the needs of ordinary health care providers, particularly those working in district hospitals and primary care?
3. How will HIN support local capacities to repackage and distribute relevant information to healthcare providers, along the lines of the electronic-print chains or 'Staging Posts' as proposed in recent months by various HIF participants (for which there are already numerous examples)?
4. Has HIN the capacity to engage more closely with various sectors working in low income countries - local and international NGOs, teachers, students, librarians and others?
GENERAL DISCUSSION
Michel Loots (Health 4 Youth / Global Health Projects) explained his work in producing CD-ROMs containing health documents of interest to developing countries. He would welcome the opportunity to produce a disc containing all WHO priced publications, and such a product would be very useful for doctors in the poorest countries.
Joan Dzenowagis (JD) emphasised the need to develop products whose content fitted well together, and to use appropriate combinations of technologies. WHO, like some other players, is reviewing its policy on reuse of its published material.
Peter Campbell (University College London) suggested that, because of lack of access to adequate information resources over many years, some health professionals in the developing world have lost the habit of information-seeking behaviour.
HP responded that many doctors in developing countries are overwhelmed with work, some being forced to hold down more than one job in order to make a living. Thus, librarians may need to 'spoon-feed' information to busy doctors rather than waiting for them to take the initiative. CDs may be more manageable than the Internet, in the first instance. The time to acquire items through inter-library loans can be a disincentive.
Oliver Oliveros (Global Forum for Agricultural Research, FAO) asked whether the language issue was being addressed by HIN.
JD acknowledged this to be an important question. There is a lot of content on the Internet and elsewhere, and, indeed, WHO publishes in a number of languages. The difficulty was in making content available where it is needed. She noted that HIN was currently conducting a pilot local-accessibility project in India, with $1 m from the Gates Foundation, which uses local languages and dialects. The Virtual Health Library (coordinated by BIREME, PAHO) is looking at how its SciELO publishing model might be applied in an Indian context.
Chris Zielinski (Health Information for Development (HID) / Informania Ltd) asked whether local content (statistics and/or journal literature) in HIN meant locally originated content.
JD replied affirmatively. Access to local originated data can be hindered by bureaucratic problems at the district, state and/or national level. HIN is trying to develop a local publishing model for research information, with partners such as SilverPlatter.
Neil Pakenham-Walsh (INASP-Health) noted that it was important to make Southern journals more available internationally, and to address the limited nature of biomedical research funding in the South.
JD responded that the accessibility of Third World literature is being addressed in the HIN project, but that HIN could not address the issue of research funding.
Michel Loots returned to the local language issue, noting that there are different communities of potential users (e.g. health professionals vs researchers). Students could perhaps do translations in return for IT hardware. Material extra to WHO content was required. A relatively limited number of books, say, 200, would address most health information needs.
JD agreed on the distinction between different user groups. National Advisory Groups would sort out those models that worked for them in order to procure relevant content. Users want good content from a variety of sources, and they want to exercise choice in obtaining it, as provided by the Internet. However, HIN is not just about content, but also provides a communications base.
Sabine Wildevuur (Like Wildfire) remarked that content would need organizing, and asked about the issue of connectivity, including technical support.
JD indicated that HIN's partners included the UNDP and the International Telecommunications Union (ITU), who were addressing this.
Sabine Wildevuur observed that corruption was an issue in some parts of the world.
Andrew Chetley (Exchange) asked how capacity building was to be addressed within HIN.
HP noted that a Peace Corps volunteer had provided invaluable IT support at the University of Zimbabwe, and wondered whether such activities could be upscaled.
JD said that the newly created UN Volunteers would have a key role in supporting this programme. HIN would support such initiatives, where possible. A training model and approach is needed that could best deliver access to and use of information and specific public health applications.
Fred Bukachi (Royal Brompton Hospital / SatelLife) commented that no single solution for connectivity would work, and noted that there was very little talk of the application of wireless technology. Where power supply is limited, then other and diverse technologies may need to be used. On the quality of content, this should be set at the local level. In other words, if acceptable locally, then this should be good enough for bibliographic databases.
Irene Bertrand (WHO) noted that the African Index Medicus (AHILA) initiative continued, and commented, with reference to earlier discussion, that librarians were likely to be better intermediaries than IT specialists because of their superior knowledge of the content needs of their clients.
AH noted that the Cochrane Collaboration had good experience in addressing issues of quality with regard to the methodology of randomised, controlled clinical trials.
JD hoped that quality standards would be set with local needs in mind. Selection criteria should be applicable for particular local contexts.
Stewart Britten (HealthProm) noted the limited use of an expert panel of UK obstetric and paediatric consultants by doctors in Uzbekistan who had problems in getting answers to internet queries.
Chris Zielinski commented on the question of needing validation of local content, noting that WHO already had various Index Medicus projects underway which selected the 'best journals' for those regions. Also, ExtraMED discs are still being produced regularly. Further, CZ asked how HIN saw itself working with NGOs, what the composition of its Global Advisory Group was, and how HIN was funded.
JD said that WHO was in official relations with a large number of NGOs and it was expected that NGOs would be prominent, as partners, in logistics support and capaciity building, in extending the remit of HIN to grassroots communities. HIN was still raising funds, for example for pilot projects, and had set itself funding targets.
Michel Loots noted that peer groups could be harnessed for training on use of the internet. In the short term, volunteers could provide much needed skills.
HP commented that trainers would need to be rewarded if their skills were not to be lost elsewhere.
Heidi Brown (ID21 Health) asked how HIN was to provide information for policy makers.
JD mentioned importance of needs assessments. Policy makers want pre-digested chunks of information, and have different training needs.
HB noted that many policy makers do not have a public health background.
Fred Bukachi, referring to Michael Loots' comments on 'peer training', noted that HealthNet in Africa had 'user councils' which centred around a 'champion'. The World Bank has supported such training in a number of countries.
Maurice Long (BMJ Publishing Group) said that publishers were keen to transfer skills so as to encourage local publishing of high quality.
Andy Haines held that, in general, clinical doctors and practitioners want access to comprehensive, critical guidelines, not original research.
JD said that this was a clear priority of HIN.
HP commented on how useful ring-bound clinical guidelines were, such as those provided by the Centers for Disease Control and Prevention (US) for AIDS, malaria and TB. Such printed information can be seen as the last step in a relay to reach the unconnected healthcare provider.
David Tibbutt (CME, Uganda) said clinical guidelines needed to be more relevant to what was feasible in field situations; for example, many guidelines and treatment handbooks recommend investigations such as Xrays and blood gas analysis that simply are not available in many health centres.
Andrew Chetley said that HP's mention of a relay should be turned on its head - the so-called 'last mile' should be seen as the 'first mile', putting the healthcare worker as the starting point and primary focus.
Michel Loots talked of 'knowledge kitchens', where books are adapted to end user requirements.
Fred Bukachi said that we need to address both ends of the relay. A HealthLinks South Africa survey of traditional midwives in the Eastern Cape indicated that their needs were different from those addressed in guidelines from the Department of Health.
Andy Haines and JD agreed that needs assessment was important.
David Tibbutt commented that the rewriting of case reports submitted by local practitioners and their subsequent publishing and dissemination in CME Newsletters in Uganda was very well received.
Jean Shaw (Partnerships in Health Information (PHI)) noted that, potentially, the Internet permits many more people to be reached.
Neil Pakenham-Walsh noted the importance of creating electronic resources dedicated to strengthening the local adaptation process, eg facilitated access to image collections, text, and other content that can be adapted and translated for local use.
Maria Musoke (Makerere University, Uganda) commented that needs assessments need to be contextualized - needs differ from place to place. 'Digests' are not for everyone. Doctors, nurses and others might have different requirements.
Andy Haines said that we should distinguish between user demands and user needs. People tend to want to build on their strengths, although their weaknesses may need addressing.
JD and Helga Patrikios agreed that resources need to be made available on the Web, and that different needs should be addressed appropriately.
Bill Posnett (3WD Bibliographic Services) noted that non-usage of facilities (such as libraries) was a general, worldwide problem. He asked whether we should concentrate on a 'hard-copy' printed materials approach or abandon that in favour of an electronic-only approach. With the benefit of hindsight and alternative scenarios, which would prove to be the most effective approach to delivering health information?
JD said that HIN hadn't considered that its approach was to the expense of other approaches. HP noted that African economies were not obviously improving, and Andy Haines noted that paper was still appropriate to many - for example, M.Sc. courses in the UK.
Oliver Oliveros asked about intellectual property rights and the copyright issue, and about the cost of information, or was it to be for free.
JD replied that the Research Access Initiative in HIN made available published material to users in countries which were Berne Convention signatories (and thus respected copyright provisions). The biomedical journals, under this initiative, will be made available either freely or at very low cost. HIN material was to be made available either freely or at very low cost. The HIN Portal is funded by the UN Foundation. Publishers and others are producing content, and HIN provides access.
Maurice Long said that BMJ Publishing was providing gratis online access, noting that the internet reduced the costs required to send printed journals by post. Charitable concerns such as the Soros Foundation were concentrating their efforts on online access.
Margaret Knight (TB Alert) commented that it may be easier to raise money for electronic initiatives than for paper-only ones, even if the latter was more effective in most developing-world local contexts.
Elizabeth Dodsworth (CAB International) asked whether tools would be available on the HIN website, and what these were.
JD replied that there would be tools on HIN to support local publishing.
Neil Pakenham-Walsh concluded by providing e-mail contributions from Guatemala, India, South Africa and Zimbabwe. Three of these focused on the need for training.
Acknowledgement: Thanks to James Brooks (CAB International), who reported these proceedings with assistance from Tony McSean (BMA).
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