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Health Information Forum: Working together to improve access to reliable information for healthcare workers in developing and transitional countries

HIF14: Computer based training and distance learning: 'Interactive Health Network'

Tuesday 14 November 2000, British Medical Association, Tavistock Square, London, WC1H 9JR

CHAIR: Muir Gray CBE, Director, National electronic Library for Health, Director, Institute of Health Sciences (IHS)

PARTICIPANTS: Bill Posnett (3WD Information Bibliographic Consultancy); Youssef Hajjar (Arab Resource Collective); Viola Artikova (BMJ); John Hudson (BMJ Books); James Brooks (CABI); Batsivah Mike Chivanga (City University, London); Andrew Herxheimer (Cochrane Collaboration); Florence Harding (Commonwealth Secretariat); Ellen Schwartz (East London & City HA); Philippa Saunders (Essential Drugs Project); Chris Zielinski (Health Information for Development); Andrew Chetley, David Curtis, Roger Drew, Christine Kalume (Healthlink Worldwide); Stewart Britten (HealthProm); Lindsay Ramsbottom (ILEP); Neil Pakenham-Walsh (INASP-Health); Liz Poskitt (Independent); Anna Mitman (Institute of Child Health); George Enyakoit (Institute of Neurology, London); Andrew Cassells-Brown, JHoskin, Murray McGavin, Ann Naughton, Sue Stevens (Int'l Centre for Eye Health); Linda Berkowitz, Harry McConnell, Phil Smith (Interactive Health Network); Cathy Boylan (John Smith & Son); Jenny Burr (LSHTM); Donna Vincent-Roa (Quality Assurance Project, US); David Morley (TALC); Tine Jaeger (Tear Fund); Randal Franzen (Teton Data Systems); Teresa Pawlikowska (UCL); Chris Coyer (Wellcome Trust); David Bramley (WHO); Mike Dobson (World Federation of Associations of Anaesthesiologists)

ACKNOWLEDGEMENTS: Ann Naughton (minutes), Cathy Boylan, Andrew Chetley, Chris Coyer (facilitators); David Curtis, Florence Harding, Teresa Pawlikowska (rapporteurs); George Enyakoit (registration).

1 UPDATE ON 'HEALTH INFORMATION FOR DEVELOPMENT'

Chris Zielinski ( [email protected] ) presented an update on the Health Information for Development (HID) project, and of work under way to launch its proposed successor, the Information Waystations and Staging Posts (IWSP) project. He referred to the information document which had been circulated earlier, consisting of a one-page summary, presenting definitions and an outline of the concepts involved, a list of project milestones, some sample output from the questionnaires that had been received, and a summary of principal findings from an early review of these questionnaires. Finally, he discussed three issues that were currently critical in the project: 1) a policy discussion, 2) a range of seed and pilot projects that were being prepared, and 3) relations with the Health Information InterNetwork.

1.1 Summary of projects

The Health Information for Development project was launched in January 2000, and aims to compile a Global Directory of Health Information Resource Centres by December 2000, based on questionnaires that are being distributed widely (see http://www.iwsp.org ). HID is seen as the first phase of the much-larger, $45 m/£30 m Information Waystations and Staging Posts project, which aims to establish a global network of 1,000 health information resource centres that will provide locally appropriate content on health issues.

1.2 Definitions

An Information Waystation is a local point of access to health information received electronically. It has a PC, CD-ROM & databases, printer, modem, reliable satellite or land telephone, and prepaid broadband Internet access. It is linked to the network of other IWs, and shares information with other IWs in a two-way flow. It has personnel who are trained in/teach technical maintenance and database use. Staging Posts will act as “relay stations”, translating and adapting information materials in order to make them locally appropriate. They will distribute information rapidly and widely, linked to health and education initiatives. They will make use of appropriate external sources of information, particularly prototype publications provided electronically, as well as sharing local information, both formal and non-formal/indigenous, in a two-way flow. They will have personnel who are trained in/teach adaptation techniques.

1.3 Current issues

1.3.1 Policies: The following key policies were under consideration within the project: 1) the existing policies, missions or visions of health information resource centres that are selected for upgrading should not be changed; 2) centres that do not apply cost recovery approaches will not be required to do so; 3) the project will work with existing centres and staff, and strengthen existing information handling and technological capabilities; the project will provide hardware, software, databases maintenance and training in technology and information handling skills consonant with the specific need of each individual centre to reach a high common minimum level of capability in all centres; the project will make an agreement with each centre covering mutual responsibilities regarding activities; and the network that is developed by the project will be associated with all other appropriate networks, and will not replace or duplicate any.

1.3.2 Pilot projects: Chris provided summary details of the partners and possible donors involved in a total of eight proposed pilot and seed projects throughout the world. The first of these that was likely to begin operations was in East Africa (partners: AMREF (African Medical Research and Education Foundation), International Partnership for Health (IPH), Regional Information Technology Training Centre (RITTC), SATELLIFE, SHARED (Scientists for Health and Research for Development)). WHO's Expanded Programme on Immunization had agreed to work closely with this project in the target countries.

1.3.3 Information Waystations and Staging Posts and the Health Information InterNetwork (HIN): Chris reported on the various communications between these two large-scale project proposals, both of which aimed at strengthening the technical capacity and ability to produce locally appropriate content of different types of health information resource centres throughout the developing world. He noted that HIN had embarked on a one-year pilot project in India, and that another pilot was being proposed for Brazil. Among the future initiatives planned by the HIN project was the creation of a Content Consortium. The group agreed that Chris would in general follow progress in HIN on behalf of the Health Information Forum, and specifically participate in the HIN Content Consortium, and report back periodically to HIF on progress and opportunities for using this growing network for the dissemination of HIF members content, and that of other NGOs worldwide.

2. 'THE INTERACTIVE HEALTH NETWORK: THE ONLINE COMMUNITY FOR HEALTHCARE WORKERS IN DEVELOPING COUNTRIES.'

Speaker profile: Harry McConnell is a neurologist who now works with the evidence-based journal 'Clinical Evidence', published by the BMJ Publishing Group, UK. He has an interest in using technology to bridge the health information gap in developing countries, and has recently started work to explore the possibility of a developing country version of Clinical Evidence. He also directs a non-profit organisation called Interactive Health using online technology as a means of addressing health inequities. Interactive Health provides a real-time interactive service for health education in developing countries using videoconferencing and is developing a portal for health care workers in developing countries. He welcomes being contacted by members of development organisations interested in collaborating on this portal to establish an asynchronous network for NGOs and health workers. <[email protected]>

2.1.1 Background: Interactive Health is a nonprofit organization using online technology to combat health inequities. It's very successful online health series on medical issues relevant to developing countries has involved many important politicians (eg Jimmy Carter, Queen Noor, Mrs. Nelson Mandela), health ministers, leading medical experts and the heads of many United Nations agencies. This series has worked tincrease both the North-South exchange and the profile of important issues in international health. This proposal will extend these efforts to meet the need for reliable health information in developing countries by establishing a portal dedicated to providing education and telehealth services for health workers in developing countries.

2.1.2 Mission: Tincrease the availability of medical information, training and support to healthcare workers in developing countries and, through them, healthcare to those in greatest need. The Interactive Health Network utilises online technologies in order to achieve this in a manner that addresses health inequities. Interactive Health regards health as a human right, multimedia communication networks as appropriate technologies and collaboration as an essential means of improving our current state of healthcare.

2.1.3 Vision: A world where everyone has equal access to healthcare and medical education regardless of who they are, where they are or their financial or political status.

2.1.4 Goals: To Establish a broad based interactive community for healthcare workers in developing countries. This interactive community would increase the exchange between developing and developed countries, between Nongovernmental Organizations (NGOs) working in international health and between local practitioners and volunteers from outside agencies. This will serve the primary purpose of increasing health promotion and medical education in order to facilitate accurate diagnosis and treatment. In addition, this project is designed to become self-funding within 7 years.

2.1.5 Channels: The network will use a combination of existing conduits for information to reach a maximum number of people and will also utilise multiple forms of media, including text-based information, video-streaming, audio-streaming, real-time interactive videoconferencing, and interactive forms of online education. The Internet, analogue and digital radio, television, ISDN and satellite will all be used. An Internet portal will be the centre of the network with other conduits used to co-ordinate and expand this base. The network will include (1) an online educational component where healthcare workers can study at their own pace, with both real-time interactive learning using teleconferencing as well as an asynchronous learning community (ALC), (2) interactive online support for healthcare workers, and (3) a store-and-forward telemedicine facility for participating healthcare workers.

2.1.6 Anticipated outcomes and impact: It is expected that the network will be used primarily by healthcare workers in developing countries and by those working in the area of international health in developed countries. These may be physicians, paramedical professionals, nurses or lay people with training and experience in healthcare. They may be local practitioners or be employed by NGOs, which may be based in developed countries. Content directed at patients and their families will be developed at a later stage in the project.

2.1.7 Innovation: While there are many web portals geared towards healthcare, this focus has generally been on recognition and treatment of common conditions in developed countries. This network will include access to information about important medical conditions and health promotion for international health. The use of multiple networks for distribution will assure maximal access to this vital information by those without Internet access as well as maximal interactivity.

2.1.8 Financial Aspects: This project will be run on a non-profit basis. It will require a total of approximately $5.3 million in development funding over the first three years of operation in addition to the in kind funding already obtained for office space, equipment, network time, software and hardware. The project will become self-funding through grants, donations, memberships (for health care professionals in developed countries) and advertising within seven years. Health workers in developing countries will always have free access to the network.

2.1.9 Contact information:

Interactive Health, Devlin House, 4th floor
36 St. George St, Mayfair, London W1R 9FA
Tel: +44 (0)20 7493 8326

Email: [email protected]
www.interactive-health.org

2.2 EMAIL CONTRIBUTIONS

(Note: The above summary of IHN was distributed on 'HIF-net at WHO' tenable input from those unable to attend the meeting in person.)

2.2.1 Alistair Bolt (Norfolk and Norwich Trust, UK) suggested getting the IHN information on the WorldSpace radio system www.worldspace.com .

2.2.2 Ann Burgess (Nutrition Society, UK) compiled and distributed a list of 'Distance learning courses in nutrition and related topics'. For further details contact [email protected] .

2.2.3 John Dada (Fantsuam Foundation, Nigeria) shared lessons learned in using ICTs tenable community health workers to upgrade their skills: (1) It is hard work starting from the field workers themselves, due to past years of neglect, pressures of everyday survival, lack of confidence, and resistance to new technology. (2) It is more effective to work with the teachers at College level – teachers are more willing to learn ICT and to encourage students to take interest. 'Our plan is that tutors and students will form an intranetwork through which local content can be developed for distance learning which the frontline workers can access.' (3) There is a severe lack of computer hardware and it would be desirable to have solar-powered computers. [email protected]

2.2.4 Sarah Dutton (DataHome, UK) suggested it was important to use local expertise to provide face-to-face support and training. It is useful to have a residential portion as part of the course. Distance education should recognize variation among end users and lack of access to a library/resource centre. Sufficient background material should be provided. Where direct ITaccess is not possible, libraries with computers may be able to provide a printed service for individual end-users. [email protected]

2.2.5 Brian Layzell (secretary of Developing Country Specialist Group of the British Computer Society, UK) indicated a useful website with over 250 links relevant to distance education technologies and telemedicine, at www.fae.plym.ac.uk/tele/tele.html / [email protected]

2.2.6 Pat Letendre (Canada), on behalf of the International Association of Medical Laboratory Technologists, expressed interest in participating in the IHN. [email protected]

2.2.7 Koos Louw (South Africa Medical Research Council) is responsible for information and communications and offered to add value to the planning process of the Interactive Health Network. The SA MRC is currently developing a national health knowledge network . Koos expressed concern that global systems such as IHN might omit to take into account country-specific systems which already exist or are emerging. [email protected]

2.2.8 Professor K R Sethuraman, a physician at Pondicherry, India, commented: (1) while cognitive skills can be upgraded through distance education, practical skills need hands-on training; (2) the proposal lacks mention of collaboration with developing-country experts to provide hands-on knowledge and training. ‘The direction of the current proposal is for ‘Expertise’ to flow from First world to Third world’. Hands-on training in developing countries is more cost-effective than similar training in developed countries. Prof Sethuraman also suggested ‘while I appreciate the WHO usage of the term ‘health workers’, the term ‘health professional’ is more appropriate and acceptable in the third world to indicate ‘professionally qualified health workers’. [email protected]

2.2.9 Jean Shaw (Partnerships in Health Information, UK) commented on the summary of the Interactive Health Network (distributed on ‘HIF-net at WHO’). She emphasized two points as essential to the sustainability and relevance of the information/training for healthcare workers: (1) involvement of healthcare workers themselves, and consultation of those who work with them (eg information workers); and (2) involvement of existing organizations and networks in-country, who might contribute to the structure and to the material being made available. Maybe such institutions could be identified through Chris Zielinski’s work for Information Waystations and Staging Posts. [email protected]

2.3 SMALL-GROUP SESSIONS: Participants were divided randomly into three groups (blue, green, red). Each group was given the task of carrying out a brief SWOT analysis of the IHN project proposal. A full proposal had been distributed tall participants a few days before the meeting.

2.4 REPORTS FROM SMALL GROUPS

Note: The individual items represented below are a summary of comments made by participants. They are not a consensus view, nor was any attempt made to prioritize them. There was, however, substantial agreement and overlap in the reports from the three small groups:

STRENGTHS

1. IHN has a global vision with great potential.
2. It is large-scale and makes maximal use of available technology.
3. The 'Portal' aspect of the project was seen as a particularly valuable and needed feature, particularly if it were able to focus on improving access to existing Web sites and electronic resources that are directly targeted t(1) primary and district healthcare workers and (2) ministries of health and other organizations that are responsible for the production of health learning materials for such health workers. No such Portal yet exists. The University of Zambia's website was mentioned as a particularly relevant existing resource in helping health workers to identify useful sources of information in the region. A Portal might include a facility for identification, adaptation, and exchange of clinical guidelines and similar materials.
4. Internet connectivity has exciting potential for distance education. Such programmes should focus on interactivity and communication, including features such as electronic 'chat rooms' for student-student, student-teacher, and teacher-teacher interaction.
5. The project will actively seek out collaboration from healthcare workers in developing countries and will assist them in developing their own content which will build on that provided and will have the potential to be shared with health workers in both developing and industrialized countries, ie the network represents an exchange of information within a community online for international health issues and not a unidirectional supply of information for developing countries.

WEAKNESSES

1. The scope of the project is perhaps too broad and too ambitious for a single project (health promotion, medical education, increase the availability of medical information, medical and related training, multimedia education, creation of broad-based interactive community, videoconferencing, telemedicine, interactive online clinical support).
2. The range of end-users is perhaps too wide (healthcare workers in developing countries – physicians, nurses, paramedics; NGOs; those working in international health in developed countries; general public).
3. Those without Internet access will be relatively excluded, , although secondary access through printing of materials will be possible
4. As with other HI programmes, there is a need for more information about existing activities, both at international and national levels, to enhance cooperation and reduce duplication.
5. More collaborations with other NGOs might be helpful

OPPORTUNITIES

1. IHN could explore ways to support existing health information groups, enhancing their connectivity and fundraising capacity. Training could be provided so that partners can put their own content on-line through the project.
2. Two-way exchange and an open forum for dialogue would be valuable as the project develops, perhaps through an e-mail list server. This would help tmaximize use of the resource. Increased dialogue might help reduce duplication, promote collaborations, and enhance sharing of lessons learned.
3. IHN could seek further collaboration, notably with the Staging Posts and Information Waystations project, which was seen to be complementary.
4. IHN could consider cost-recovery through charges tend-users (though many felt this would prevent access).

THREATS

1. The project may not provide the right information tits end-users. It is important to avoid any assumption that we in the North know what is needed. Instead we should ask clearly what the needs are. Local needs assessment is required.
2. Even if the project could provide relevant information, it is well known that provision of information in itself is not enough to ensure that the information is accessed and applied.
3. There is a risk that the project may fail to engage 'resonance' – ownership, buy-in – with its end-users and partners. This will result in lack of participation by organizations and end-users in developing countries. There is a need to look at who will benefit from the project and ensure that the project has resonance for these groups. The project was being conceived in the UK, which may make it difficult to achieve a wide sense of ownership in developing countries.
4. In the long-term, the project (like most health information projects for developing countries) will be challenged by sustainability.

2.5 DISCUSSION

In the discussion which followed, participants made a number of points about the difficulties encountered in reaching 'the last mile':

• As one contributor noted, there is a distinction between information that educates and information that is practical for a particular purpose. Another contributor noted that the project is about education, and this is the scaffolding on which practical information stands. It is important to encourage people to do as much as possible for themselves.
• In communicating information, there is a distinction between concepts and the practical ways in which these concepts are put into use. In giving information on dosages, for example, it is not enough to give the correct dosage but also to explain what happens if the dose exceeds a certain level. In this instance, context is vital.
• Reaching the end-user effectively raises many issues, including (1) language and (2) wording, sentence structure, etc. The way of presenting content in clear simple language is vital. This will also make it easier to translate. There is an opportunity to incorporate these issues into this project from the outset.
• Is this the last mile or the first mile? If local content is to be included, then it is the first mile that will be most difficult. The FAin one of its projects found for example that what they thought was the 'last mile' was in fact the 'first mile'.

In concluding this session, Harry McConnell thanked participants for the opportunity to present the project and obtain feedback that would assist in its development. He noted that the IHN were themselves juggling the issues of local flavor and assessing local needs. One idea is that the IHN would provide information which can be locally adapted. In addition, it would provide access to web tools so local content can be developed. They are very much aware of the need to encourage sharing between centres, rather than North-South. He gave the example of a video conference requested by partners so that they could learn from the success of the Uganda HIV/AIDS programme.

For further information, please contact the IHN project direct at [email protected] . Please send further comments and suggestions to IHN and/or to ‘HIF-net at WHO’ at [email protected]

3. GUEST PRESENTATION BY DONNA VINCENT-ROA

(Quality Assurance Project, US): 'Strengthening health service delivery in developing countries with computer-based training'

Donna Vincent-Roa is Director of Communications, Associate Project Director, and Director of the Technology for Performance Group, URC.

Presentation Structure

• Project Overview
• Why Computer-Based Training?
• Organizational Readiness
• Quality Performance Learning Series and Current Projects
• Research
• Constraints and Limitations
• Partnerships and Collaborations

The Quality Assurance Project

• Improve the quality and efficiency of care by helping lesser-developed countries institutionalize quality assurance
• Provides technical support to service delivery institutions, Ministries of Health, USAID Missions, and field-based cooperating agencies

Why Computer-Based Training?

THE RESEARCH

• Alternative to traditional medical training
• Practical solution for organizations with limited resources
• Delivers a satisfying learning environment and ensures information content and quality

Why Computer-Based Training?
CONTRACT REQUIREMENT

• “Take advantage of training interventions and approaches that offer the potential for improved cost-effectiveness”
• Project Goal — develop and field test CBT tool for quality assurance

Innovative Training Approaches

• QAP has played a leadership role in:

  applying a CBT approach tIMCI

  developing a TB CD-ROM that contributes to improved compliance with WHO guidelines for correct TB case management

Why Computer-Based Training?
THE OUTCOMES

• Builds human capacity
• Guarantees transfer of critical skills
• Increases access to information
• Provides training where there is no trainer

Organizational Readiness
CBT ISSUES PAPER

• The Use and Effect of Computer-based Training in Healthcare: What Do We Know? Looks at effectiveness of CBT in healthcare and application in developing country settings

Organizational Readiness

• Established the Technology for Performance Group to:

  manage the development of CBT

  define and develop formal processes to support the design, development, production, testing, implementation, and marketing of CBT products

  generate new CBT business opportunities

Quality Performance Learning Series

• Developed to improve health worker performance and promote good health outcomes
• Cost-effective, innovative, computer-based learning tools strengthens competencies, enhances learning, and increases knowledge of health providers

Current Projects

• TB Case Management – English, WHDOTS-based training
• TB Case Management – Spanish adapted to Bolivia healthcare context
• Quality Assurance Kit
• IMCI - Uganda version
• IMCI - generic version
• IMCI – Spanish, adapted to Bolivia healthcare context

TB CD-ROM

• Used to train health workers in the latest TB care methods — all aspects of prevention, diagnosis, and treatment
• Can be used for pre- and in-service training or as a refresher
• TB CD-ROM Contents
• Provides users with an engaging and stimulating learning environment
• Helps user to master all aspects of TB case management
• Pre-tests and post-tests

TB CD-ROM Contents

• Large collection of DOTS forms and reference materials
• Other features: colorful graphic icons, audio narration, computer tutorial
• Second Place Winner, Minnesota Design Competition, 2000

Operations Research
Field Testing – TB

• Tested in Ethiopia with 100 doctors
• Results: health workers who use this CD-ROM had higher competency scores than those who use traditional paper-based training

Quality Assurance Kit

• Developed as an alternative training method to build capacity in QA skills and support operational teams in the field
• To address low computer competency, QAK includes several components to enhance computer skills

Quality Assurance Kit

• Contains the latest QA methods and tools
• Provides a tutorial on how to use the computer
• Allows Internet and e-mail interface
• Winner, Silver Cinema in Industry Award (CINDY Fall 1999)

Operations Research
Field Testing – QA Kit

• Ethiopia field-test results used for final upgrades
• Technical operation, ease of use, navigation, cognitive load, mapping, screen design, information presentation, media integration, instructional design, and attitude of users

Quality Assurance Kit

• Refinements underway
• Case studies and tools are being refined
• Revised beta version Fall 2000
• Additional field testing planned
• Partnering program with several healthcare organizations and NGOs
• QAP wants to adapt the generic QA Kit tan IMCI-QA Kit to further enhance health worker performance and algorithm compliance

IMCI CD-ROM

• Developed two years after the WHO/UNICEF IMCI global initiative to train health workers in the IMCI clinical guidelines in collaboration with the Uganda MOH
• A multi-media course that mirrors the traditional course
• Allows for simulated patients and testing

IMCI CD-ROM
PRODUCT GOALS

• Shorten the standard in-service IMCI training course
• Provide refresher or pre-service training
• Expand the reach of IMCI training to health professionals not typically included in standard training

IMCI CD-ROM

• Second version has received WHO financial support for content and functionality upgrades
• WHO interest and support in beta testing the final product in 2001

Operations Research
Field Testing - IMCI

• Ugandan government interested in exploring alternatives to standard training
• Adapted to Uganda context
• First field test in Uganda

Uganda IMCI Study

• 54 in standard course
• 59 in CBT course
• Result - knowledge and performance tests (2 week and 3 month testing) – scores almost identical

Uganda IMCI Study Results

• Results of the cost analysis reveal that when compared to traditional classroom-based IMCI training, CBT was almost 30 percent cheaper per trainee (omitting development and hardware costs)
• Requires only 9 days and fewer facilitators to conduct the training

Uganda IMCI Study Results

• Course is less taxing to facilitators and less expensive, even if computers need to be rented
• Participants seem to prefer the CBT course, even though none had ever used a computer before
• New CBT courses may lead to increased knowledge and retention of information

Constraints Identified in Uganda Field Research

• High cost of computers – either for purchase or hire
• Need for ongoing and routine computer maintenance, servicing, and security
• Power surges and power outages
• Constraints Identified in Uganda Field Research
• Computer not available at the district level
• Limited district resource allocations for training

IMCI CD-ROM

The Future

• Current version being updated and revised modern interface, tutorials, six patient simulations, a glossary, student tracking
• Additional field testing of the new version planned
• Adaptation to French and Russian being considered by external partners

CBT's Potential

CBT learning environment

• Independent
• Self-paced
• Interactive
• Shorter course of study
• Fewer instructor interactions
• More cost-effective

CBT's Potential

• Can be copied or shared among a large number of users
• Serves as a reference material for up-to-date learning
• May be the only learning tool available to a health professional

Partnerships and Collaboration

• Identification of new markets
• Product testing, development, and adaptation
• Research on cost-effectiveness
• Product reviews/placement
• Public information and advocacy

Partnerships and Collaboration

• Develop an adaptable CBT architecture for rapid deployment in other languages and health contexts
• Expand CBT development to include malaria, HIV/AIDS, diarrhea, etc.
• Establish journalism training in health
• Develop in other subject areas based on client needs

QAP Value-Added Areas

Experience in:

• Alternative learning technologies project management
• Medical and health background and expertise
• Product testing and research capabilities

QAP Value-Added Areas

• Ability to design performance support solutions
• Extensive network of subject matter experts
• Culturally sensitive and multi-lingual staff

A Call to Action

• Mobilizing political support and financial commitment
• Setting up partnerships and business arrangements for CBT development and marketing.

The Health Information Forum is run as an activity of INASP-Health, a cooperative network for organizations and individuals working to improve access to reliable information for healthcare workers in developing and transitional countries. Participation is free of charge and without obligation. INASP-Health is supported by the BMA, Danida, ICSU-Press, and WHO. INASP is a programme of the International Council for Science (ICSU).