MEDICAL INFORMATICS IN GHANA

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					MEDICAL INFORMATICS
     IN GHANA
    Yaw Ofori-Adjei B.Sc.(Med Sci)
  University of Ghana Medical School
          28th February 2003
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
LAND MASS OF 238,537 Sq Km
           Political History
• Gained Independence in March of 1957

• Series of Coups after independence

• Last Coup was 1981 by Flt Lt J.J. Rawlings

• Military Rule for 11 years ( J.J. Rawlings)

• J.J. Rawlings elected president in 1992

• J.A. Kuffour, President 2000 - Date
•Ten (10) Administrative Regions

•110 Districts

•The district is the unit of planning
 and political administration

The Capital City is Accra
              Economic
• Foreign exchange is from export of
  Timber, Cocoa, Pineapple, Gold, Diamonds
  Bauxite and Tourism

• Domestic Economy revolves around
  agriculture which contribute 36% of GDP
  and employs 60% of work force
                  GDP($)       Per Capita Growth
                                   ($)    Rate(%)
Ghana          39.4 Billion    1,980      3.2
USA            10.08 Trillion 36,300           0.3
Nigeria        105.9 Billion   840             3.5
South Africa   412 Billion     9,400           2.6
                                  World Bank Estimates 2001


Ghana opted for debt relief under the Heavily
Indebted Poor Countries Initiative (HIPC) in 2002
                   People
• Total Population is 19.7 Million (2001)

• 36% of Population is Four Urban Areas of
  Accra, Kumasi, Sekondi-Takoradi and Temale
• Small ethnic groups which Speak 50 different
  languages and dialect
• English is the official language

• 60% of population are Christians 16% Islam
  and rest, African Traditional Religion
Trivia
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
        Health Care System
•   Before a health care system was established by the
    British in 19th Century, African traditional medicine
    was practiced

•   Health services was then solely for Europeans

•   Services was extended to Ghanaian people
    in the late 19th Century

•   In 1923, the Korle-Bu Teaching Hospital was
    built. It has remained the main referral hospital
    and a model for other hospitals in the country
    Health Care System
               Structure

• Current system is a three-tiered system
  • National
  • Regional
  • District

• Focal point of the system is the district level
National

 •   MOH – Policy formulation, monitoring and evaluation
     of progress in achieving targets
 •   GHS – Allocation of resources and creation of
     partnership with private sector

Regional
 •   10 Regional Health Administrations serve as link between
     the national and district levels and allocate resource within the
     region

District
 •   DHMT – Concerned with operational planning and
     implementation of service within the district.

 •   Health facilities; Hospital, Health centres, posts and clinic
        Health Care System
               Hospitals
Teaching Hospitals              2
Regional                        8
District                        48
Government Funded               23
Charity                         43
Private                         39
Total                           165

           592 Health Centres
        Health Care System
                   Finance
•   After independence medical services were free
    and financed by the government

•   User fees were introduced in 1978, a cost sharing
    system nicked named “Cash and Carry”

•   Health finance then came from public funds, hospital
    fees and charitable aid.

•   Current government is instituting a National
    Health insurance scheme to replace the “Cash and
    Carry” system
                      USA     Ghana   Nigeria     S. Africa
Life expectancy at    76.9    60.0    51.6        49.0
birth (years)
Healthy life          67.2    47.8    41.9        41.3
expectancy at birth
(years)
Child Mortality       8       104     156         97
Adult Mortality       114     332     390         561
Total Health          4,449   51      20          663
expenditure per
capita(US $)
Total Health          13.0    4.2     2.2         8.8
expenditure as % of
GDP

                                                WHO 2002
        Health Care System
            Donor Community
Department for International Development, DFID
Danish Agency for Development Assistance, DANIDA
United States Agency for International Development, USAID
Japan International Cooperation Agency, JICA
United Nations Children’s Fund, UNICEF
The World Health Organisation, WHO
United Nations Population Fund, UNFPA
Nordic Development Fund, NDF
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
         ICT Landscape
•   Majority of Companies are Hardware Sales
    and repair

•   The Market is rapidly growing

•   Market Size is $35 Million

•   3rd Largest US Export Market in Sub-Sahara
    Africa after South Africa and Nigeria

•   2001 sales was $4 Million an increase of 46%
    over 2000
         ICT Landscape
            Telecommunications
•   Service Market estimated $171 Million in
    annual revenue(1999); Estimates for 2002
    are $400 Million

•   Services offered;
    • ISDN
    • Wireless Internet Access
    • VSAT
    • Dialup Internet Access
    • VPN

•   Equipment Market annual revenue $60 Million;
    Estimates for 2002 are $200 Million
ICT Landscape
Telephone use

•   Total monopoly of fixed lines by
    Ghana Telecom
•   Total fixed lines 250,000
•   Teledensity of 76/1000 persons
•   5 Mobile Phone Operators offering
    • GSM, AMPS, ETACS
    • Analogue
    • GPS services
    • Satellite Telephones
•   Total Mobile Lines 300,000
    ICT Landscape
           Internet Access

•   46 Licensed ISP, 10 operational

•   Dialup subscribers are 8,000

•   Average Cost is $25-$44/Month

•   Cyber Cafés are the growing trend
    • 1,400 in Accra
    • Each Café has an average of 10 pcs
    • Average Cost is $1/hour

•   Main use is Free Web based email
                                1997 2000              2001
Personal Computers per 1.6               3.0           3.5
1000 people
Telephone Lines per             6.9      18.1          76
1000 people
Internet Users                  5,000 30,000           200,000
      Source: WorldBank Development indicator database, April 2002
      ICT Landscape
         Software Development

•   Mainly Confined to Financial Sector

•   Development is mainly for WINTEL
    platforms

•   Open Source is mainly used by
    • ISPs
    • Students and
    • Hobbyists

•   To date there has been only one open
    source project in Ghana and West Africa
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
Medical Informatics

   1. Medical Research

   2. Public Health

   3. Clinical Informatics
             MIMCom.NET
          A malaria research network for Africa

•   Formed in 1997 at Multilateral Initiative on Malaria
    conference in Dakar

•   African scientist identified lack of communication as
    a major barrier to carry out their work; combating the
    morbidity and mortality of Malaria

•   A working group was formed to discuss ways in which
    research scientists in Africa may have the same level
    of Internet access as colleagues elsewhere in the world

•   The National Library of Medicine was charge with
    leading the effort to create the necessary
    communication network
         MIMCom.NET
      A malaria research network for Africa

Features:
•   Allows researchers an open link to send and
    receive mail

•   Search Medical literature and databases

•   Sharing of files and images

•   Permanent, continuous access 24 hours a day
    7 days a week

•   Minimal cost to participating users
         MIMCom.NET
      A malaria research network for Africa

Design:
•   NLM designed and operates the network and covers
    all necessary costs;
    • Determination of requirements and site survey
    • Negotiation with African Telcom authorities
    • Assistance with equipment purchase & Installation
    • Training and support
    • Establishment of document delivery system and
         information portals

•   Individual sites and funding partners are responsible
    for equipment costs and cost of shared bandwidth
         MIMCom.NET
      A malaria research network for Africa

Implementation:
•   Network technical hub located at Redwing Satellite
    Solutions(UK)

•   Large satellite dish focused on geo-stationary
    satellite 37,000km above the Atlantic Ocean.

•   Ground station connected to high speed internet
    back bone on the ground.

•   VSAT were installed at Research sites to access
    Network
MIMCom.NetMIMCom.NET
         A malaria research network for Africa

     Implementation:




 Ghanaian Sites
 1. Noguchi
 2. Navarongo
         MIMCom.NET
      A malaria research network for Africa

Evaluation:
•   NLM and International Centre of Insect Physiology
    and Ecology in Kenya are currently doing the
    first evaluation of the network.

•   Evaluation covers;
    • Network performance
    • Efficeint use of bandwidth
    • Information use and site growth
    • Papers published and
    • Collaborations carried out
                 HealthNet
•   This is the SATELLIFE’s Global Communication
    Network which links Health workers around the
    world by email

•   HealthNet utilized SATELLIFE's low- earth-orbit
    satellite to establish e-mail connectivity in various
    locations throughout Africa.

•   Allowed Health care providers who had been working
    in isolation were finally able to communicate, share
    experiences and access information critical to their work.

•   Ghanaian researchers use HealthNet to communicate
    with London School of Hygiene and the Tropical Disease
    Research Centre in Geneva
                  HealthNet

•   In what has been described as a major public health
    success story in recent times, African researchers
    used the network in the control of Onchocerciasis

•   This was as a result of Multinational collaboration
    including Ghana to track the Black Fly (Simulium)
    larvae, the vector of the disease along the Volta river
         SATELLIFE’S PDA
            PROJECT
•   A collaborative effort between SATELLIFE and the
    American Red Cross Society(ARC)

•   The project was to demonstrate the Usefulness and
    Feasibility of using relatively inexpensive handheld
    technology in the conditions found in Africa.

•   Phase One of the project was carried out in Ghana
    during a massive measles immunization campaign
    by the ARC in December of 2001
         SATELLIFE’S PDA
            PROJECT
•   Paper surveys are normally used by the Red Cross to
    gather data, which is then manually entered into a database
    and analyzed to plan a follow-up campaign

•   The process is cumbersome, time consuming, expensive,
    and prone to human error.

•   This surveys were therefore not always conducted
SATELLIFE’S PDA PROJECT
•   It was hypothesized that this survey
    • could be done quickly and accurately and
        encompass a large sample.

    •   Results would be in a timely manner that would
        facilitate planning for future measles and other
        public health efforts.

•   A short user-satisfaction survey was also loaded onto the
    PDAs for the surveyors to fill out after they returned from
    the field. Questions included topics such as
    • problems encountered
    • ease of use and
    • comparison to a paper-based survey
SATELLIFE’S PDA PROJECT
 Results
1. Individuals who were not familiar with computer
   technology were easily trained and deployed to collect
   data. They completed 2,425 surveys at 67 locations in the
   targeted region including 41 urban and 26 rural sites.
   They averaged 28 surveys per person per day.

2. The PDAs were utilized in the field with no disruption
   from elements such as dust, dirt, and sunlight nor was
   loss reported due to security or breakage.
SATELLIFE’S PDA PROJECT
 Results(Cont.)
 3. Data was downloaded from the units rapidly and with no
    error enabling rapid analysis and prompt reporting to the
    local Ministry of Health. The 30 paper surveys took
    approximately 30 minutes to enter into a data base, a rate
    that would have taken over 40 hours to enter the PDA
    surveys by hand.

 4. The user satisfaction survey yielded positive results
    1. 70% said PDA was easy to use
    2. All were able to keep the screen clean
    3. 87% had no problem reading the screen outdoors
    4. 10% found it too confusing to follow.
SATELLIFE’S PDA PROJECT
Conclusion
•   The project was a success.
•   The speed and ease of gathering data was unprecedented
•   The in country costs was $2000
SATELLIFE’S PDA PROJECT
   Phase Two
1. The Project tests the viability of the handheld computer
   for gathering information that is critical to decision makers
   and policy makers, and for disseminating information
   among health professionals in Kenya and Uganda.

2. 80 PDAs were shipped to Two Universities in Kenya and
   Uganda where they will be distributed to 6th year medical
   students and physicians for clinical use in a variety of settings.
   SATELLIFE’S PDA PROJECT
The PDAs contained the following medical content:
1. Medical textbooks from Skyscape:
   1. 2002 Griffith's 5-minute Clinical Consult
   2. Harriet Lane Handbook
   3. 5-minute Pediatric Consult
   4. A to Z Drug Facts
   5. Pocket OB/GYN

2. HIV/AIDS, TB, and Malaria guidelines specific to Kenya
   and Uganda
3. MedCalc, a medical calculator with over 40 formulas including
   a pregnancy calculator
4. World Health Organization(WHO)Essential Drug List
5. Essential Drug List specific to Kenya and Uganda
    SATELLIFE’S PDA PROJECT
•   An independent evaluation, conducted in December 2002,
    will examine the usefulness of both the technology and the
    content, especially as they impact the behavior of health
    professionals and the quality of care they deliver.

•   The results of the survey is important to Ghana especially
    since a lot of health practitioners are not aware of and
    do not have access to HIV/AIDS and other clinical
    guidelines that are critical in diagnosis and treatment.
        Clinical Informatics
Electronic Medical Record
• Non-existent

•   Processes is paper based; ADT, LAB, Radiology etc

•   Access and retrieval of patient information is time
    consuming and very frustrating

•   Disjointed and Lack of Coordination in Patient
    management
Activity Diagram of
 a Physician Order
      Clinical Decision Support
•   The Ghana National Drugs Programme and MOH
    produce an “evidence based” treatment guideline in 2000

•   This Guideline is not being used as expected because;
    • It’s not readily available to does who need it most
    • Those who have it, find it inadequate because it
       contains out-dated information and its generic
       nature of recommended management

•   No tools for Alerts or provision of patient specific
    recommendations
          Medical Knowledge
•   Medical journals are source of knowledge and
    the most used source of information

•   Use of Online versions of these journals are minimal
    • Ignorance of the existent of these resources
    • Cost of subscription to the journals
    • Low level of computer literacy amongst potential users
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
      Potential Gains
1. National Health Insurance Scheme
2. Telemedicine
3. Advise of policy makers
4. Disaster Management
Potential Gains - Health Insurance
•   The National health insurance scheme which is to
    replace “Cash and Carry” starts later this year.

•   The scheme would be run by local mutual health
    organisations who are likely to either use of-the-self
    software or have one written for them

•   There is the consideration of a unique ID system that would
    allow patients to cross district lines for specialist care.

•   Medical informatics would help create standards for
    electronic exchange of financial and administrative data
    and also standards for unique identifiers, code sets,
    security and privacy
    Potential Gains - Telemedicine
•   Particularly useful in rural settings that have no doctors and
    in regional hospitals that lack specialists e.g. radiologists

•   Patient findings can be described in email and their
    investigations such as ECGs and x’rays may be sent as
    attachments for expert consultation.

•   Cheap($200), easy to use and robust digital cameras with
    high resolution images (2.1 megapixels) may be used in
    teledermatology and perhaps telepathology and
    teleultrasound
Potential Gains – Disaster Management
•   Appropriate use of information technology can be of
    enormous help to those responsible for disaster management
    e.g perennial outbreaks of Cerebrospinal Meningitis in
    Northern Ghana and Cholera and other diarrhoeal disease
    in the rainy season.

•   Adequate and timely flow of information would be use in
    prevention, advance warning, early detection, notification
    of appropriate authorities, mobilization of response,
    containment of the disease and medical care for those
    affected.
    Potential Gains – Policy Advise
•   Effective sharing of information amongst the various
    stakeholders in healthcare delivery would aid the
    formulation of better health policies.

•   Irrelevant and unnecessary repeatition of research by
    organisations within the Ministry of health would
    decrease if there is collaboration amongst them and
    knowledge created by these organisations are readily
    available and accessible.
    Outline
• Introduction
•   Health System
•   ICT Landscape
•   Medical Informatics
•   Potential Gains
•   Barriers
•   Conclusion
          Barriers
1. Financial


2. Poor communication infrastructure


3. Irregular power supply


4. Lack of trained professionals in
   • Medical Informatics
   • Telecommunications
                Conclusion
1. Ghana stands to benefit from the application of
   informatics in health care.

2. There are however several pre-requisites that it needs
   to meet before an effective and sustainable system can
   be put in place

3. Use of existing infrastructure and appropriate
   technology may reduce the cost of implementation

				
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