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

Workshop 7: `Information Waystations' and `Staging Posts': connectivity and the complementarity of electronic and print media

Royal College of Physicians, London, Tuesday 7 September 1999

Contact: Neil Pakenham-Walsh, Programme Manager, INASP-Health,

INASP, PO Box 516, Oxford OX1 1WG, UK

Tel: +44 (0)1865 249909 Fax: +44 (0)1865 251060.

Email (Health): [email protected] ; WWW: http://www.inasp.info/

Chair: Richard Smith (Editor, British Medical Journal)

Speaker: Christopher Zielinski (Co-Chair, HIF Staging Posts Action Group)

Participants

• Alexander Heroys (AMREF)
• Barbara Kirsop (Bioline Publications)
• Liz Woolley (CABI)
• Florence Harding (Commonwealth Secretariat)
• Manjit Kaur (ECHO International)
• Philippa Saunders (Essential Drugs Project)
• Paul Chinnock (FSG MediMedia)
• Bryan Pearson (FSG MediMedia)
• Andrew Chetley (Healthlink Worldwide
• Roger Drew (Healthlink Worldwide)
• Victoria Richardson (Healthlink Worldwide)
• Neil Pakenham-Walsh (INASP-Health)
• Peter Bewes (Independent)
• Liz Poskitt (Independent)
• Caroline Hyde-Price (Royal College of Nursing)
• Anna Tomlinson (Royal College of Physicians, London)
• Resoum Kidane (Sheffield University)
• Gerry Dingley (TALC)
• Mary Tamplin (TALMILEP)
• Christopher Coyer (Tropical Medicine Resource, Wellcome Trust)
• Gerard Robinson (World Federation of Societies of Anaesthesiologists)

PROCEEDINGS

Announcements and Forum business

The meeting began with news from Neil Pakenham-Walsh and Andrew Chetley, who had been involved in the working group of the UK Department for International Development's 'Health Communications Partnership Study'. (Background: This study had been commissioned in September 1998 by the Health and Population Division of DFID as part of the process of reassessing its entire health sector strategy. The study looked in particular at how DFID might increase the effectiveness of the resources it invests in health communications and information work. The final report with recommendations based on a consultative review was presented to DFID in May 1999.)

The DFID working group had learned from DFID that the report had been well received and the recommendation of level 2 - a networking and learning programme with a ceiling of 500,000 pounds per year - was the most likely to be adopted. The study group would be meeting again on 17th September to provide further provisional details on the programme for DFID, and contributions to this were welcome. Further details would be disseminated as and when available, and discussed on a consultative basis.

It was proposed that the next meeting of the Forum (HIF8, 16 November) should be devoted to consideration of the position of Health Information Forum in the DFID proposal, instead of taking the more general look at fundraising which had been planned. After some discussion it was agreed that this should indeed be done as the opportunity was too good to miss.

Workshop Proceedings: `Information Waystations' and `Staging Posts'

[Note: The current workshop looks specifically at a proposal presented by Chris Zielinski. The Health Information Forum's role in this context is to provide a NEUTRAL space according to its stated Objective `as a focus for the exchange of ideas, experience, information, and contacts, aiming to avoid duplication of effort or reinventing the wheel, as well as prevent avoidable mistakes.']

Background papers - including copies of the proposal - had been distributed to all participants in advance of the meeting. These background papers are available by email or in print from the INASP office.

Working definitions

Information Waystation

An IW is an information resource centre equipped with a computer, CD-ROM player, printer, modem, satellite telephone, software, pre-paid broad-band Internet connectivity, CD-ROM databases, linked to IW administration and the network of IWs. Maintenance and training would be provided twice a year, covering at least the operation of the hardware, software, the use of the CD-ROM databases and of the Internet.

IWs are about improving connectivity and building the IT capacity of a range of resource centres that would then function as a network.

The “pure” IW collects information and makes use of or distributes it unchanged.

Staging Post

A Staging Post is any local publisher or dissemination centre that receives information materials from various sources and carries out whatever translation, reworking and adaptation of the materials is required to make them locally appropriate. The goal of a Staging Post initiative would be to improve the range and quality of existing source information – and, particularly, improve the electronic provision of prototype publications that can be adapted and printed by national and local publishing programmes. The emphasis is therefore on content, not infrastructure.

Presentation: The Information Waystation Proposal (Chris Zielinski, Co-Chair, HIF Staging Posts Action Group)

Let's start with a couple of quotes. The first is from William Gibson, an author who coined the term "cyberspace". Speaking to TIME Magazine recently, he was quoted as saying, "The future is here, it just hasn't been distributed yet." In a nutshell, that is the Information Waystations proposal - distributing the future.

The second quote is more of a factoid - Happy Birthday, Internet. The net was 30 last week, on the 2nd of September to be precise. Since its birth, the baby has grown rapidly among the populations that care about such things. To be sure, it hasn't grown quite as fast as its boosters have claimed. I have been writing a paper for some time now called "Lies, damn lies and Internet statistics". If you look at the amazing predictions, and then at the statistics, we see a clear case of boosterism. The fact is that we currently have 179 million online worldwide.

Looking briefly at the situation in developing countries, Africa has been lagging. Nevertheless, Lishan Adam in an excellent paper presented at an INASP-sponsored meeting recently provided the following information, which I am summarising in the next few slides.

So there is progress in the deployment of information and communication technologies in Africa, however slow - and there is optimism, however cautious. Lishan Adam mentioned the key problems in deploying ICTs from the perspective of the country. There are also well-known, even notorious problems from the perspective of a development project, which are summarized in this slide..

Thus, with this background in mind, and arriving from two separate directions, as described in your background paper, the concepts of Information Waystations and Staging Posts were developed. At first, we thought they were one and the same thing. As time and discussions went on, it became clear however that it was worth distinguishing different characteristics. Again, these definitions are in your background paper. The Information Waystation is technologically enabled, while the Staging Post is content enabled. I should stress at this point, since there have been some doubts expressed on this matter, that the Information Waystation project proposal includes the provision that some of the Waystations would also become Staging Posts. Thus, although we are separating out and distinguishing the two concepts, the project proposal seeks to bring them together.

Now, before winding up this brief introduction I wanted to tackle a couple of the strongest issues that seem to have arisen from the copious activity on the Staging Posts Action Group list. I should first note that we are beginning to arouse plenty of interest around the world, and that the mailbag has been running strongly in favour of the project.

A number of people have asked about the relationships of this project with other network activities. I've been inundated with news of other activities relating to connectivity - in Africa the very interesting Leland project and the Acacia project. In Bangladesh, the Grameen Bank's decision to finance the establishment of 6,000 "computer kiosks" throughout the country, connectivity news from Zimbabwe and the Congo, from Russia... We had a proposal in the Action Group to consider a category of "Associate Information Waystations" to deal with complementary networks, and as a way of growing our own network activities more rapidly. I think the watchword will be "complementarity".

Another key issue relates to the relative primacy between the information waystations model and the staging posts model. Surely it is more important to provide health information accessible to the greatest numbers in the most appropriate way, while improving connectivity must be of smaller priority. I have no problem with that at all. I fully subscribe to the idea that all the computerisation in the world is useless unless appropriate information comes out of the wires. But, while we are trying to figure out how to solve the local appropriateness issue, why not improve the tools we are using, since it is relatively easy to do? In my view, and this is how the present project proposal has been formulated, a straightforward project about capacity building with a staging-post component is more likely to achieve funding than a complex (and it would have to be that, judging from all the recent discussions) project about staging posts with a capacity-building component. Conversations with donors have reinforced my belief in this notion. And I also believe that an approach initiated from a capacity-building perspective will lead to the rapid development of staging post materials. This naturally does not preclude working up a second project where the focus is on the content, and I would invite the Staging Posts Action Group to consider this as its next agenda item

Finally, let's focus on what the present project proposal is about. It is about first identifying suitable resource centres for upgrading so that they can participate in the Information Waystations network. What kind of resource centre is this? Unless there is a very clear commitment from a non-computerised resource centre to invest on their own to add staff and take on the added burdens of training and management, I would make it a pre-condition that the resource centre already has a functioning computer or two, with staff who have somehow learned to operate the equipment. It might already have a CD-ROM player and MEDLINE on CD-ROM, but little else; and possibly a slow or limited-access e-mail connection, but no full Internet connectivity.

Now, if you take that as a starting point, the addition of a brand-new, reliable computer, a fast contemporary CD-ROM drive, an additional collection of particularly relevant CD-ROM databases and a fail-safe satellite telephone connection offering pre-paid full-bandwidth access to the Internet - surely all this would simply make life at that resource centre easier, faster and better all around. The effect of the project would then be to allow the staff more time and better quality information as a starting point for their development into Staging Posts - if that is what they want to do.

A word about the price, because I have seen some raised eyebrows - this is small beer compared to what is spent on other programme areas, and compared with the money available. The PATH Child Vaccination programme was recently established with $100 million from the Gates Foundation, and foundations are piling up money that they cannot spend. We need good project proposals that tackle achievable, measurable, evaluable tasks successfully. This is a $50 m project over five years; we could propose another one on Staging Posts covering assistance in that area. These ideas are not mutually exclusive.

As I exit, I must comment on exit strategy. It is, of course, the same question in every information project. What happens to the MEDLINE/BMJ/textbook provision after the end of project funding? There are very few instances where an information project in a developing country has managed to find its own funding from local sources as a result of its own activities? If you can't do it for MEDLINE, how are you going to do it for Information Waystations? The difference here is that the IW project may be large enough to end up having the clout to keep pulling in contributions from large donors and countries. IW activities could be funded, and increasingly SP activities as well (and I believe - from the pragmatic point of view, but not necessarily the priority point of view - that that is the correct way round).

The term of the present project proposal is five years, which is the amount of time we will have to secure the next tranche of funding. I have no serious illusions about recipient countries suddenly slapping their foreheads in the realisation that they should be allocating national monies to this - at least not for a long time. Meanwhile, it is a challenge set to the project administration to find the funding to continue the project until then, even if at present we must concede that this may be indefinitely.

In closing, I would observe that there is no end to information projects. Information is such a weasel word, that almost everyone has a different concept of what is important, which target audiences ought to be addressed, which regions and countries, which technologies, which information. Given this, one has to work piecemeal, and even in a project that seems as expensive as this one can only tackle a few components of the total need.

Discussion groups

The meeting divided into three groups for focused discussion on Chris's proposal. The discussions took the form of a SWOT analysis: strengths, weaknesses, opportunities, threats. At the plenary session which followed rapporteurs presented the groups' deliberations under each of the four SWOT headings.

The Chairman suggested that Chris Zielinski could respond more fully to the comments made in writing when the report of the present meeting was prepared. Accordingly, Chris's comments on the Weaknesses and Threats are given as an addendum at the end of this report.

It should be noted that the following lists represent a brainstorm of potential SWOTs, each of which was raised by one or more persons. There was insufficient time to make a consensus statement or to prioritize the lists. None of the statements should be considered to represent a consensus view.

STRENGTHS

S1: “The need for improved health information is great and, if successful, the IWs proposal could help meet it.”

S2: “It would strengthen those resource centres in the South which became IWs.”

S3: “IWs could also improve the flow of information from South to North and South to South.”

S4: “It is good that the proposal includes a survey of the existing health information situation.”

S5: “The Internet is a powerful tool that has yet to be put to use in this area. It is good to see a proposal which seeks to do this.”

S6: “There is considerable enthusiasm amongst donors for projects that involve IT. The time, therefore, is right to seek funding for this kind of activity.”

S7: “New information could be distributed rapidly.”

S8: “It avoids the `electronic or paper?' debate as both media would be involved at different stages of the process.”

S9: “The sheer scale of the proposal is one of its strengths, although it some ways it is also a weakness.”

S10: “IWs might provide a focus for the considerable enthusiasm that exists within the organisations represented in the Forum for finding new ways of transmitting health information.”

S11: “The project would build on the experiences of health information providers and improve networking between them.”

S12: “Useful lessons would be learnt which could have applications in other aspects of development.”

WEAKNESSES

W1: “The target audience / end users of the health information to be transmitted via the IWs has not been clearly defined in the proposal, nor the precise nature of the health information these end-users need.”

W2: “The difficulties of those health workers who did not speak English had not received attention.”

W3: “The time allowed for the initial survey is too short. The survey should include an attempt to discover what kind of health information healthcare workers themselves actually wanted, not just what resource centres / potential IWs thought they wanted.”

W4: “A project like this should be demand-driven if it is to stand a chance of success. The nature of the demand for better health information is not clear. The demand for electronic health information does not perhaps exist at all as yet. This is largely because people are unaware of the possibilities, but `awareness raising' does not figure in the proposal.”

W5: “The project should also be content-focused and needs-orientated, and this is not adequately reflected in the proposal.”

W6: “The health information transmitted could be focused on `popular' issues instead of being needs-related.”

W7: “There is a danger that the status quo could be reinforced, whereby information is generated in the North and passed down to the South. Care would have to be taken to avoid the IWs project becoming prescriptive and top-down.”

W8: “Measurable outcomes have not been defined. This would make it hard to determine whether IWs were succeeding.”

W9: “There is no previous experience of a project of this nature. Bold steps are admirable but a more cautious start, with pilot projects, might be more advisable.”

W10: “The scale of the project would create administrative problems. It was impossible to predict all the problems which could arise; pilot projects would help discover what these were.”

W11: “Onward transmission from waystations to frontline healthcare providers would be a more difficult process than getting information TO the IWs and this seems not to receive enough attention in the proposal, even allowing for the fact that the appropriate methods for onward transmission would have to be decided locally. Pilots would offer a chance to see what kind of approaches work best.”

W12: “The amount of information on the Internet which is relevant to frontline healthcare providers in resource-poor settings is still small and time/resources would be required to put those written materials which do exist into electronic form.”

W13: “The process of selecting resource centres suitable to become IWs would take longer than allowed for in the proposal.”

W14: “Staffing requirements/training would be considerably greater than allowed for in the proposal.”

W15: “Similarly insufficient allowance had been made for maintenance.”

W16: “The use of satellite telephones is fraught with problems.”

OPPORTUNITIES

O1: “The flow of appropriate health information would be stimulated. So would appropriate research.”

O2: “IWs would act as a stimulus to put more health information on the Internet that was relevant and of good quality.”

O3: “IWs offer an opportunity to channel enthusiasm.”

O4: “IWs could form the basis of CME activities.”

O5: “Library development would be assisted.”

O6: “IWs could go on to develop a range of other functions, for example in health education or management training.”

O7: “Successful projects could be replicated, repackaged, adapted etc.”

O8: “Health information could be linked to healthcare projects.”

09: “Systematic information training could be introduced.”

O10: “There would be a multiplication effect; the number of IWs would grow.”

011: “Other projects could also use IWs as prototypes.”

THREATS

T1 “IWs, instead of gateways to information, could become bottlenecks.”

T2 “Resource centres that became IWs could benefit as institutions but fail to pass health information on as intended.”

T3 “Misunderstandings could arise, increasing feelings of marginalisation amongst those healthcare providers who did not benefit.”

T4 “Quality control would be difficult to assure and this might result in unhelpful or incorrect information being passed on.”

T5 “There could be dangers of replication. Where adequate health information materials do exist in paper form (which is more accessible to most frontline healthcare workers), why duplicate them on the Internet?”

T6 “End-users might be persuaded that high-tech solutions were always the best, whether appropriate or not.”

T7 “After the initial investment in IWs was over it might prove impossible to sustain the initiative.”

T8 “The dating of hardware, leading to incompatibility problems, could be a major problem.”

T9 “Theft of equipment could occur.”

T10 “There could be copyright problems.”

T11 “IWs might fail to collaborate usefully with health ministries.”

T12 “Political tensions could be exacerbated, for example if neighbouring countries did not want to network.”

T13 “Once donors had invested in IWs they might become complacent, considering that no more needed to be done to support health information work”

T14 “Should the IWs project fail after such considerable investment, it could be very damaging for health information efforts in general.”

Plenary discussion

The Chairman invited Chris Zielinski to comment briefly on the SWOT analysis. Chris said that many of the weaknesses and threats could be avoided; the comments made during the meeting would help make it possible to do so. For example, the survey of resource centres would clearly have to seek to establish what health information needs actually were, and the need for health information to be relevant would have to be borne in mind throughout. The training component of the scheme would also address the various potential problems. Individual IWs, however, would have responsibility for the approaches adopted towards such matters as onward transmission of health information, local language etc. They would also have to raise awareness of what they were seeking to do in their own area. They would have to help create a culture where information was seen as having value. Measurable objectives were hard to define but clearly important; it would be easier for IWs to define their objectives than `Staging Posts'. In general, he felt that the weaknesses and the threats identified by the participants were important things to watch out for, rather than fatal flaws.

Chris said he was pursuing further potential sources of funding. The comments of the meeting would be reflected in a revised version of his project proposal. However, development of the IWs project was something he was doing on a purely voluntary basis. It was proving to be very time consuming and there was a limit to how long he could continue on this basis. It was suggested that before funding was obtained for the project itself a small grant should be sought to fund the pre-project activities.

Several participants said a small number of Staging Posts (which could be regarded as pilot projects) might be preferable to the large number of IWs envisaged in the project proposal. [Chris's comments on Staging Post pilot projects are given in the addendum below in response to W4, 9 and 11.]

In conclusion, Neil Pakenham-Walsh suggested the 'Staging Post Action Group' might now review what had been learnt from the SWOT analysis and plan their next steps accordingly. Emphasizing the political costs to the global health information community should any large scale project be implemented and fail, Neil suggested the measure of success for SPAG would not be whether or not the project (or a modification) would go ahead. Rather, the group's success might best be measured in its ability to make the right decisions based on the information available, taking into account the views of colleagues from the North and South.

ADDENDUM: Chris Zielinski's responses to `Weaknesses' and `Threats'

At the meeting, the Chairman suggested that Chris Zielinski could respond more fully to the comments made in writing when the report of the present meeting was prepared. The following is Chris Zielinski's response.

1. `Weaknesses'

W1 “The target audience / end users of the health information to be transmitted via the IWs has not been clearly defined in the proposal, nor the precise nature of the health information these end-users need.”

CZ: This is certainly true. As a starting point, the target audience/end users will be the same as is/are being addressed by the existing resource centres, and the health information will be more of the same materials that they are currently using. Until research has been carried out into the present capabilities and aims of the resource centres, we cannot describe the nature of audiences or information with any degree of accuracy.

W2 “The difficulties of those health workers who did not speak English had not received attention.”

CZ: I appreciate what the questioner is asking, although this is putting it awkwardly! The difficulties are surely not so much those of the health worker but of health information providers who are failing to provide information in languages appropriate to their audience. I hope that the project could help in this a) by making the needs of the audience more clear to the information providers, b) by encouraging the development of Staging Posts to carry out local adaptation, including translation, and c) by foraging widely for existing materials in appropriate languages. This should indeed be made clear in the project proposal.

W3 “The time allowed for the initial survey is too short. The survey should include an attempt to discover what kind of health information healthcare workers themselves actually wanted, not just what resource centres / potential IWs thought they wanted.”

CZ: A good point. I imagine that the initial survey (whether it takes six months or a year) will continue indefinitely as the project progresses, and our knowledge of the needs and capabilities of resource centres develops. As to finding out what the health workers want, this strikes me as a project opportunity – we could try to develop the questionnaires and other techniques to support efforts by local resource centres to identify local information needs.

W4 “A project like this should be demand-driven if it is to stand a chance of success. The nature of the demand for better health information is not clear. The demand for electronic health information does not perhaps exist at all as yet. This is largely because people are unaware of the possibilities, but `awareness raising' does not figure in the proposal.”

CZ: Let's consider the two aspects of the project separately – on one hand capacity building, and on the other the provision of appropriate information. I think that the case is pretty clear as regards the demand for improving the technological capacity at resource centres: remember, we are talking about putting fast modern computers in places where they have slow old machines; providing full, high-speed, prepaid Internet access where they have expensive slow, erratic e-mail-only connectivity; adding further CD-ROM databases to their existing MEDLINE or POPLINE. Do you really need to demonstrate a demand for upgrading equipment and software?

The demand for locally appropriate materials also seems (intuitively) to be strong, although – as I mentioned in connection with the W1 above – surely we are only aiming to assist in the distribution of more and better materials?

Finally, the demand for the “whole enchilada” – how do you demonstrate the need for a 1,000-centre network? You certainly can't demonstrate such a need with a prototype!

W5 “The project should also be content-focused and needs-orientated, and this is not adequately reflected in the proposal.”

CZ: Should it be “content focused”? That's certainly one of the options for a given resource centre, but you cannot force resource centres to be anything other than what they are. If you are building capacity to obtain information, you can encourage the resource centres to obtain good and useful information through the better facilities you have provided, but nothing more. The answer may lie in the policies relating to prioritisation for inclusion in the project. Of course, this point may be simply the assertion that “the provision of appropriate content should be the main activity of this project, not capacity building”. I suppose one could say that about every information project! As for “needs oriented”, that comes back to W4 – if technology doesn't solve any need then it shouldn't be applied. The project will only help those resource centres where technology is currently being used and the resource centre considers it essential to the reception of health information and dissemination to its chosen target audiences, and expresses the need to improve its technology.

W6 “The health information transmitted could be focused on `popular' issues instead of being needs-related.”

CZ: Well, it could be focused on almost anything. That's one of the wonders of information and problems of information projects!

W7 “There is a danger that the status quo could be reinforced, whereby information is generated in the North and passed down to the South. Care would have to be taken to avoid the IWs project becoming prescriptive and top-down.”

CZ: Yes, I absolutely agree with this. I think it is crucial that information from the South be given some prominence in this project.

W8 “Measurable outcomes have not been defined. This would make it hard to determine whether IWs were succeeding.”

CZ: Yes, another crucial requirement. One can measure capacity building in various ways, but it is a chronic problem of information-development and ICT projects that there is a dearth of indicators to assess the impact of information on development. There is some research work (notably the IDRC-sponsored work), but not enough practical research. Actually, I see this more as an opportunity for the project, which could embark on some ground-breaking research work in this area once the network has been established.

W9 “There is no previous experience of a project of this nature. Bold steps are admirable but a more cautious start, with pilot projects, might be more advisable.”

CZ: See W4 above – personally, I don't see the need for pilots regarding capacity building/Information Waystations, since there have been many such trials, and I don't see how one could construct a prototype of the network itself, almost by definition, since a network is something that provides benefits precisely because of its large size. Prototyping might be particularly appropriate in the Staging Post concept.

W10 “The scale of the project would create administrative problems. It was impossible to predict all the problems which could arise; pilot projects would help discover what these were.”

CZ: Again, how can you use a small pilot to show what administrative problems could arise in a large project because of its large size? In general. It is of course true that any large ICT project will have important administrative requirements that will have to be managed carefully. Fortunately, there are many precedents for large-scale ICT projects working successfully.

W11 “Onward transmission from waystations to frontline healthcare providers would be a more difficult process than getting information TO the IWs and this seems not to receive enough attention in the proposal, even allowing for the fact that the appropriate methods for onward transmission would have to be decided locally. Pilots would offer a chance to see what kind of approaches work best.”

CZ: Yes, I agree. The need for pilots is precisely in this area of providing appropriate content on a large scale. This is mentioned in the proposal, but should certainly be strengthened.

W12 “The amount of information on the Internet which is relevant to frontline healthcare providers in resource-poor settings is still small and time/resources would be required to put those written materials which do exist into electronic form.”

CZ: I think this is a challenge to information providers of all kinds everywhere. Perhaps one of the effects of a large-scale network of the kind being proposed will be to convince such bodies as WHO to provide prototype materials on a much wider scale than heretofore. Efforts such as the Cochrane Collaboration's, OMNI and HealthNet are particularly relevant here.

W13 “The process of selecting resource centres suitable to become IWs would take longer than allowed for in the proposal.”

CZ: This is possible. Remember that, for a 1,000-IW project, we would aim to identify and reinforce 200 in Year 1, a further 400 in Year 2, and the final 400 in Year 3. Thus, building on the research conducted in the 6-9-month pre-project phase, one would “only” need to have the first 200 identified.

W14 “Staffing requirements/training would be considerably greater than allowed for in the proposal.”

CZ: To be discussed. It is important to distinguish a) the training requirements of people who are already using computers to select and make use of information, and who already know something about databases and the Internet from b) the training requirements related to publishing/translation/editing etc. IW training can probably be as short and cheap as the proposal suggests, while SP training is a much more extensive and costly affair.

W15 “Similarly insufficient allowance had been made for maintenance.”

CZ: To be reviewed. It will depend on whether local facilities are available, on the sort of input one might received from any donors of hardware and software, etc.

W16 “The use of satellite telephones is fraught with problems.”

CZ: Somewhat sweeping! I have seen some very good examples – for example, BT's Satelan, using INMARSAT satellites, which is easy to install, operate and maintain, and provides ISDN bandwidth for data and voice communications (end of unpaid advertisement!)

2. `Threats'

T1: “IWs, instead of gateways to information, could become bottlenecks.”

CZ: How? We are building on existing resource centres – how could the simple fact of improving their technology suddenly cause them to perform any worse?

T2: “Resource centres that became IWs could benefit as institutions but fail to pass health information on as intended.”

CZ: As intended by whom? Surely the project is about empowering resource centres to achieve their aspirations, not ours. Our aspirations would be built into the project policies, and particularly in the selection criteria that we apply in choosing resource centres for upgrading. The selection process is crucial in identifying resource centres that would make good IWs – while, at the same time, achieving their own priorities, and providing the maximum benefit to the communities they serve. I can't quite envisage IWs collecting tons of health information for their own gratification!

T3: “Misunderstandings could arise, increasing feelings of marginalisation amongst those healthcare providers who did not benefit.”

CZ: Yes – an important issue to consider. Though I would imagine that the flow of more and hopefully better information would have the reverse effect, especially if it reached more healthcare providers.

T4: “Quality control would be difficult to assure and this might result in unhelpful or incorrect information being passed on.”

CZ: Yes, always true in information projects.

T5: “There could be dangers of replication. Where adequate health information materials do exist in paper form (which is more accessible to most frontline healthcare workers), why duplicate them on the Internet?”

CZ: To make them more widely available elsewhere; to create a repository, archive or library of valid information. The same could be asked about printing, publishing or libraries, which only exist to make or store “duplicate” copies. In any case, IWs would not be obliged to put their health information materials on the Internet.

T6: “End-users might be persuaded that high-tech solutions were always the best, whether appropriate or not.”

CZ: Yes, I agree that this is a risk to be borne in mind, but would note that this observation applies to such innovations as the motor car, combine harvester, packet soup and printed word. It also applies equally well in the First World. A major aspect of the project is to improve technology in those resource centres which have already made their pact with the devil!

T7: “After the initial investment in IWs was over it might prove impossible to sustain the initiative.”

CZ: Yes, sustainability is an issue, and is always a particularly thorny issue in information projects. It may seem paradoxical, but I feel that a large information project is more likely to prove sustainable than a small one.

T8: “The dating of hardware, leading to incompatibility problems, could be a major problem.”

CZ: Replacement of hardware is built into the project plan.

T9: “Theft of equipment could occur.”

CZ: Yes.

T10: “There could be copyright problems.”

CZ: Yes.

T11: “IWs might fail to collaborate usefully with health ministries.”

CZ: This should be considered in relation to the success/failure of existing resource centres to collaborate usefully with health ministries – would the upgrading proposed make this worse (and I'm not necessarily saying that it wouldn't!)? The point is well taken that this project should collaborate clearly, openly, actively and from the very outset with the ministries of health in all countries concerned.

T12: “Political tensions could be exacerbated, for example if neighbouring countries did not want to network.”

CZ: I suppose the point is that governments may not want their citizens to communicate with citizens of other governments, but is (fortunately) not easy to prevent people who have Internet access from communicating with each other. This is not to make light of the political ramifications of increasing connectivity, which must certainly be appreciated.

T13: “Once donors had invested in IWs they might become complacent, considering that no more needed to be done to support health information work.”

CZ: Personally, I think that one of the principle possibilities and functions of such a network will be to enable far more large-scale health-information provision activities than have been possible to date.

T14: “Should the IWs project fail after such considerable investment, it could be very damaging for health information efforts in general.”

CZ: This can be said about any large project – and in general about any large investment. It's not good to fail! But consider the nature of possible failure – for example, some of the IWs could stubbornly refuse to do anything useful with the new resources they have been provided, despite the best efforts of the project. Some technical malfunctions could prove resistant to maintenance. Some equipment could be stolen or misused. I feel that small failures are possible, and perhaps even likely, but (to be negative about it, and taking a classic risk), I can't see how any large-scale failure is possible! On the other hand, with the input of considerable preliminary research and an all-embracing policy-setting effort, I feel we can envisage large-scale success.