E-Health Futures for Bangladesh
Sohail Inayatullah
2012-08-14 00:00:00
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To answer this question, the Bangladesh Ministry of Health, and Bangladesh Enterprise Institute in collaboration with the Rockefeller Foundation promoted a three-day foresight workshop on the futures of digital or e-health. This continues Bangladesh’s leadership in the ehealth area. [1]

Participants came from a number of areas – e-health start-ups, hospital directors, leading physicians, professors of public health, e-health practitioners, international e-health experts, Ministry of Health directors and digital information/business providers.

Three visions of the futures of e-health were articulated by participants.

LEAP-FROG 2025

The first was the Leap-frog. In 2025, the smart use of technology through low-cost diagnostic devices such as medical “apps” and bio-sensors created a dramatic transformation in healthcare. The traditional (modern Western) health system was leapfrogged. Individuals throughout Bangladesh gained access to inexpensive interactive technologies. The e-health infrastructure developed from the bottom up. The Ministry of Health provided the standards and other rules to ensure integration and interoperability.

The metaphor used by the Leap-frog group was the “fly-over”. Given traffic congestion in Bangladesh and the inability of more roads to solve demand, the guiding metaphor was aptly named, “Fly-over.” The leap-frog was possible as though an integration of extensive stakeholders, a “fly-over” from the current state of affairs (politicization of health, high demand, but inability to meet health needs, lack of penetration of new ICTs, and high penetration of mobile phones[2]) to a desired E-health future was created.

A day in the life of a case worker in this future might consist of the following: (1) Rupa receives an alert on the mobile device; (2) she then retrieves past patient information from the EHR (electronic health records database); (3) Rupa collects recent patient vital statistics using mobile medical devices and bio-sensors; (4) she then forwards the information to the doctors’ platform for remote diagnosis; (5) she facilitates a healthy and meaningful relationship between doctor and patient through quality service provision; and (6) helps keep the geo-mapping and profiling of patients and diseases proactively. There is high-tech with meaningful human contact.

In the Leap-frog/fly-over future new mobile smart technologies are used instead of the landline. However, the service provider is the key in this future. The rural or urban community worker is the knowledge health navigator that bridges the world of the patient and the medical system. New applications are created. The health worker is not a passive recipient of new technologies but an active creator.



THE HEALTH CLOUD 2025

In this vision of the future, the guiding metaphor is that of the “cloud” referring here to cloud computing, wherein health information and diagnostic applications are available ubiquitously to all. The “cloud” is a public space, however, for administrative purposes. Health is organized through upazilas or sub-districts (currently there are 500 in Bangladesh). The beginning of the Cloud health network is through tracking of the birth of every child in Bangladesh. Once the births are registered then their health life-cycles can be tracked, monitored and life stages health-enhanced.

For example, a day in the life of an end-user could look like this:

Rahima Begum just delivered a baby boy in Shadullapur health complex. Within 25 minutes, she and her family received a birth certificate and national registration number. Baby Zahir receives a baby bracelet with an embedded RFID tag, which will allow any health worker to check and update his health record. When baby Zahir’s vaccines are due, his family, and his community health worker will receive an SMS notifying them of the vaccine and the near test health centre where the vaccine is in stock.

After the first week of life, Rahima Begum receives a visit from the health extension worker who delivers her postpartum vitamin A, which is registered, using the RFID bracelet, to update the cloud health record. Her cloud health record is updated, and the district civil surgeon's statistical flat panel screen is updated, so he can plan with the District Education Officer the probable size of the incoming primary school class in that village. Rahima Begum's husband, who is a migrant worker in Dubai can access on the internet, with a secure password, the updated health record of his family, and motivate the family to ensure they get vaccines on time, and to make sure baby Zahir receives only exclusive BF. He has used the Cloud Learning function to learn about infant nutrition, and insists that the grandmother not feed any animal milk.


In the Cloud, persons do not need to move; only data does. Health information, expertise and wisdom come to the patient. Multiple stakeholders support the system.



SUSTAINABLE PUBLIC PAYMENT FOR HEALTH 2025

In this third vision of the future, the other scenarios are accepted, but the primary question is the payment mode of future systems, their financial sustainability.

This future is centralized with individuals provided financial incentives to stay healthy via public disbursements. This system had already begun to occur in 2009.[6] Thus, prevention as a worldview has become dominant. [7] Donors and insurance agencies, along with the government and health professionals, have a major role to play in this future. Information is not just one way, i.e., giving citizens health education but through the financial incentives and new mobile technologies it has become two-way. Citizens use new digital devices or work with local health case workers to enhance their own understanding of their personal tailored health futures. They are empowered and thus costs are lowered. [8] While inequity may become a problem, the system does not negatively discriminate against those that are unhealthy due to genetic or environmental factors. These are taken into account.

A day in the life of Hassan may look like this in 2025:

Hassan gets up in the morning with a stomach ache. The e-health bracelet on his arm is buzzing, notifying him about an anomaly in his body structure and that an automated interview has been set up with his doctor, complete with his bio-data and current symptoms. Hassan can sense trouble; the overdose of samosas last night is going to cost him a hike in his insurance premium, which also means another visit by the insurance guys shortly. As he got up from his bed, he also realized that he had to notify his landlady to receive the medications, which automatically would be sent over to his house, immediately after his visit to the doctor. The phone bell rang up; it was his HR manager at office, who had requisitioned a half-day leave for him, as his sickness had been notified to his workplace. As his health costs have gone up, Hassan is far more careful about over-eating. And he knows he should have used the applications on his health phone to monitor his diet but …he did not. In the future, he will be more careful.


Employers thus provide incentives to workers to stay healthy via wellness programs and mobile health solutions. They monitor their own health, and thus have incentives to stay empowered.





DIGITAL HEALTH SUCCEEDS – Data comes to the patient

Digital health in Bangladesh is likely to succeed because of technological advances and because the current health system is faltering (low doctor/patient ratio, low public access to health services) and the leadership exhibited by the numerous stakeholders. E-health visions promise futures wherein patients are more empowered; community health workers use health diagnostic devices to monitor, link with medical professionals and track individuals. Revolutions in e-records, e-pharmacy, e-diagnosis and e-prevention transform Bangladesh health leading to greater wellbeing and economic productivity. The Ministry of Health provides the standards and safeguards to ensure public health benefits. Medicine – data, information and wisdom – come to the patient. This system is especially important given potential future shocks such as dramatic climate change (and an ageing society [9]).

Because of the success of e-health initiatives, the health of Bangladeshis was transformed. Specific outcomes were: (1) increased life expectancy, (2) lower mortality, (3) the elimination of maternal and infant mortality, (4) universal healthcare, (5) economic growth and (6) increased wellness.




REFERENCES


[1] The United Nations awarded Bangladesh an award for its leadership in digital health. http://www.dghs.gov.bd/. Accessed 27 November 2011.

[2] Estimates are that 50% of Bangladeshi citizens use mobile phones. Anisur Rahman, “New rules to take services to the poor,” Gulfnews.com http://gulfnews.com/business/banking/new-rules-to-take-services-to-the-poor-1.882078. Accessed 4 October 2011.

[3] http://www.intple.com/case-page_en/healthcloud.html. Accessed 2 10 2011.

[4] Onuora Amobi, “VMware Streamlines Electronic Medical Record Delivery Through Spectrum Health's Cloud Computing Environment” http://www.cloudcomputingzone.com/2011/02/vmware-streamlines-electronic-medical-record-delivery-through-spectrum-health. Accessed 2 10 2011.

[5] Robert Langreth, “Use Bribes to Stay Healthy”, Forbes Magazine 24 August 2009, http://www.forbes.com/forbes/2009/0824/executive-health-medical-use-bribes-stay-healthy.html . Accessed 2 October 2011.

[6] Anne Fisher, “More companies are paying workers to stay healthy,” Time (21 May 2009). http://www.time.com/time/business/article/0,8599,1899915,00.html. Accessed 2 October 2011. Kevin Volpp, “A Randomized, Controlled Trial of Financial Incentives for Smoking Cessation,” New England journal of medicine, 360, 2009, 699-709. http://www.nejm.org/doi/full/10.1056/NEJMsa0806819. Accessed 2 October 2011.

[7] See Sohail Inayatullah, “Changing the health story from passive acceptance to active foresight,” Futures, Vol 42, 2010, 641-647.

[8] For an example of this in terms of health literacy, see Raquiba A. Jahan, “Promoting health literacy: a case study of prevention of diarrhoeal disease from Bangladesh”, Health promotion international, Vol 15, No. 4, 2000, 285-291. http://heapro.oxfordjournals.org/content/15/4/285.full. Accessed 2 October 2011 .

[9] M. Kabir, “Demographic and economic consequences of Aging in Bangladesh”, Online Publication, Centre for Policy Dialogue, Bangladesh. http://www.cpd-bangladesh.org/publications/cunfpa3.html. Accessed 3 October 2011. Mesbah-us-Saleheen, “Aging: a creeping problem for future society? The Daily Star (6 July 2005) http://www.globalaging.org/elderrights/world/2005/creeping.htm. Accessed 3 October 2011.