African e health economics Forum: Amanda Brikmann Chair: 2 sessions: Context for e-health, notes + actions to move forward: A discussion

AFRICAN E-HEALTH ECONOMICS FORUM
22 NOVEMBER 2012
ONE AND ONLY HOTEL: CAPE TOWN
SUMMARY, NOTES, ACTIONS: PANEL DISCUSSIONS ONE AND TWO
PREPARED BY THE CHAIR: AMANDA BRINKMANN
NOVEMBER 2012

P.O. Box 49, Klapmuts, 7625 Peace of Heaven, Protea Road, Klapmuts, 7625
Indigo Promotions T/A Indigo Consulting Reg: 1989/036933/23 Mobile: +27 828900663
E-mail: ab_indigo@iafrica.com

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KEY ACTION POINTS, CONCLUSIONS AND RECOMMENDATIONS FOR IMPLEMENTATION: AFRICAN EHEALTH
ECONOMICS FORUM
22 NOVEMBER 2012
1. Creating the proxies and measurement metrics within a framework: to measure the benefits
and Return on Investment [ROI] of e-Health – including actuarial modelling.
2. Investigate the Beijing International Medical Centre model – as example of best practice.
3. Create clear eHealth policy for South Africa & SADC – including operational and
implementation policies and plans – standardised as far as possible.
4. Sustainability – including sustainability planning and metrics within the framework – specifically
related to maintenance, upgrades, upkeep and future budgeting
5. Institutionalise eHealth at the highest levels – Cabinet and Parliament – so that it becomes a
national priority.
6. Reinforce the notion that we must first „ get the basics right‟ – including the use of LEAN/Sigma
methodologies to deal with process and systems flow, strengthening the existing infrastructure,
equipment backlogs and staff shortages – thereafter the technology must he developed to
deliver the desired OUTCOMES.
7. Cost-Benefit analyses: Crowd local and global methodologies and case studies and present in
a format – so as to agree analyses framework for South Africa and Africa.
8. Preparation Phase – pre the arrival of the technology: Include Change Management processes
+ the cost of initial reduction in productivity; include training, support and maintenance within
implementation plans and budgets.
9. Basic computer literacy/skills – do a national assessment at all health facilities to establish levels
of computer literacy – as baseline, to determine extent and range of training interventions that
would be required pre-roll-out of an eHealth system.
10. Reiteration of the fact that we should: “ Describe what we WANT eHealth to do, draw the
picture, iterate the desired outcomes – and design the system around those outcomes”
11. SATMA to investigate the Telemedicine Switch – which acts as an aggregator and therefore
liberates the environment.
12. Connectivity audit – baseline study to be done at all health facilities – could be done
simultaneously with computer literacy study/survey.
13. Technical assistants: 2 year apprenticeship for Out-of-School Youth who show the aptitude for
ICT – accredited training and creation of micro-enterprises to serve clusters of medical facilities.
14. Consider Regional Implementation and Co-operation – in Africa – rather than countries
implementing separately.
15. Formalise what we mean when we speak about „Partnerships‟ – what do these partnerships look
like – define the range of possible partnerships clearly – from transactional to CSI.
16. Develop norms and standards – developers to work with clinicians/public and private health
17. Financing Methodologies MUST be agreed and developed – eHealth cannot be rolled out
without a clear financial commitment and strategy.
18. Draw on existing Assessment Methodologies available – Dr Craig Fredericks – GSM Global – to
provide study reports, including Bihar, India project – training 35 000 Community Healthcare
workers, using technology
19. Define e-Health – what is it, how does each dimension or element fit into the system and how
are each of these measured fairly?

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20. Consider models where there is risk and cost sharing between the public and private sectors.
21. Structure expectations of all partners upfront – as part of collaboration.
22. Healthcare typically uses historical or incremental budgeting – suggestion that the „ new‟ model
of healthcare should be clearly defined and a return to zero-based budgeting so as to reflect
the „ new‟ needs of citizens and the system.
23. Operating Leasing – with finance partners – including the upfront purchase of maintenance
contracts, to mitigate against and/or neutralise the cost of finance at fixed rate – over time.
24. Create a CENTRAL REPOSITORY to: * Leverage „ appropriate‟ IP/Best Practice/Success Modelling
* National and International best practice and knowledge crowded – access of all interested
parties so as to share knowledge, avoid duplication and created a shared vision and eHealth
agenda.
25. Look at the connectivity Spine/Backbone and Cloud Computing – create definitive policies,
norms and standards.
26. Advocate for eHealth as enabler to „get the basics right‟ and part of process of health systems
strengthening.
27. Patient-centricity: Access anywhere, anytime – design the business processes and system to
support patient-centricity and to ensure that value is added to the patient experience.
28. Inter-operability is vital – develop norms and standards.
29. INTEGRATED PLANNING – full stop.
30. Cost containment, maintenance, replacement, capital costs – all to be factored into the
framework.
31. EHEALTH ENTERPRISE ARCHITECTURE – is at the core of being able to move forward – a national
enterprise architecture must be completed – so that all provinces are able to align
implementation accordingly.
32. Share South African eHealth strategy draft document – attached separately for circulation. [4]
33. South Africa and SADC partners to become members of Health Level 7 [ HL7][8], so as to draw on
existing global best practice in respect of eHealth standards and frameworks.


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1.

SESSION ONE: ASSESSMENT: THE MOST SUITABLE METHODS OF TRACKING SUCCESS AND
ENSURING PROJECTS ARE GIVEN SUITABLE TIMELINES FOR SUCCESS

1.1 WORKGROUP OUTLINE/DIRECTIVES
1.1.1
1.1.2
1.1.3
1.1.4
1.1.5
1.1.6

Health system analysis: What have we learned and how do we do better?
What are the economic benefits to the various stakeholders in healthcare?
How is healthcare quality impacted
How do employers benefit?
What emphasis is being given in developing countries to cost-effectiveness and cost-benefit
of prevention versus curative treatment?
Use of outcomes measures, including Patient Reported Outcome Measures, in resource
allocation

1.2 PANELLISTS
1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
1.2.6
1.2.7
1.2.8
1.2.9

Chair: Amanda Brinkmann – Indigo Business Consulting & Advisor to the Minister of Health as
well as Leader of Government Business: Western Cape Government. Head: Strategic
Partnerships: Western Cape Government [ Last effective day of tenure with WCGOV]
Dr Simon Samaha – Physician Leader in Europe, Middle East and Africa – PWC
Trish Dicks – Strategic Account Manager: ECM: Public Sector – Datacentrix
Badie Niewoudt – New Business Development Manager – Eli Lilly
Makano Mosidi – Public Sector Executive – Dimension Data
Deputy Minister Makoae – Lesotho Department of Health
Aphiwe Mazambo – Health ICT – Western Cape Department of Health
Rosemary Foster – Division Manager: eHealth Strategy and Policy – Medical Research
Council
Bakang Oliphant – Senior Manager Strategic Planning, Monitoring and Evaluation – Free
State Department of Health

1.3 SETTING THE SCENE AND CREATING CONTEXT – AMANDA BRINKMANN – CHAIR
In conversation with Andrew Bell, Programme Director of the African e-Health Economics Forum, it was
agreed that the panel sessions would be completely interactive and that firm action points would
emerge from these sessions. The Chair felt that given the fact that the same questions seem to be
asked annually at a global level and seem not to have been definitively answered or dealt with, that
this particular forum should take the lead in moving forward on a more action-oriented process, which is
outcomes-driven.
To set the tone of the conversation and to catalyse robust discussion and debate, the Chair made the
following opening remarks: 1.3.1
1.3.2

1.3.3

Health system analysis [HSA] is a distinct methodology that should be developed and
practiced in the design of policies and programmes for health systems strengthening. [1]
In the Abstract of their discussion document, Health System Analysis for Better health System
Strengthening, [1] Berman and Bitran confirm that health system strengthening and reform
are actions that are necessary so as to achieve better overall outcomes. What is required is
health systems strengthening for RESULTS.
Essentially, HSA should identify key elements of health systems analysis and situate these
within a logical framework, supported by a wide range of data and method – including


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1.3.4
1.3.5
1.3.6

1.3.7
1.3.8
1.3.9
1.3.10
1.3.11
1.3.12
1.3.13

1.3.14
1.3.15
1.3.16
1.3.17

1.3.18
1.3.19
1.3.20
1.3.21
1.3.22

within the sizeable global academic and scientific research literature that is readily
available.
The authors propose that HSA includes: * Evidence of health system inputs * Processes *
Outputs – and the analysis of how these combine to produce the outcomes. [1]
Robust HSA should consider the politics, history and historical context as well as current and
future institutional arrangements.
HSE should propose the causes of poor health system performance and suggest how reform
policies and strengthening strategies could improve overall performance. [1] It therefore
should contribute implementation as well as evaluation of methodologies to improve
performance.
The authors cite examples of best practice and successes achieved in Mexico, Ethiopia and
Turkey – these examples demonstrate the positive contributions of HSA to the development
of successful health system strengthening policies.
They further assert that HSA should be an integral part of good practice in health system
strengthening – this includes: policy development, monitoring and evaluation. [1]
The authors also remind us that HSA is a complex undertaking, requiring sound evidence and
analysis, political skill and will and they even suggest that a bit of „good luck‟ for success in
improving the outcomes is not uncommon. [1]
They ask the very pertinent question that seems to be one that is globally perplexing – and
that is: Do we have a framework?
They furthermore wonder whether the health system is accelerating outcomes or indeed, as
we suspect, impeding progress?
There are multiple goals, objectives, outcomes and outputs within the health system – what
are these variables and do we have the ability to measure them?
They conclude that HSA has to be broad, inclusive, analytical, relevant and evidence-based
– and should ideally include quantitative as well as qualitative data. One has to view the
whole system first and then the various sub-systems, to understand their impact on one
another.
In their presentation entitled: “Assessing socio-economic and clinical benefits from eHealth
solutions – approach and evidence [2], Stroetmann et al takes us a step further on the
eHealth journey.
The authors start of by asking the pressing question: “IS eHealth an enabler for better
health?” They frame this question against the backdrop of the 40 year + history of huge
investments in eHealth with what they describe as “limited” success.
They also ask: “Will what is technologically feasible or desirable, be economically viable or
organisationally implementable?” [2]
We are reminded that the “new” model of healthcare focuses on health, rather than “sick
care.” This should therefore translate to the provision of individualised health services at the
patient‟s point of need and that this can be achieved only via a collaborative, integrated
and seamless package of services and care.
The question that therefore flows logically is: “Can eHealth help us to move from reactive to
preventative to predictive medicine? “ [2]
Can eHealth help us to reduce Polypharmacy – which is becoming a near global “ disease”
category, which involves the Prescription Cascade, which becomes the Prescription
Avalanche of medications, medicating chronic patients into an early grave. [3]
The authors [2] look at the socio-economic impact of inter-operable eHealth record and eprescription systems in Europe and at the impacts.
They propose generic methodology, methods and tolls for economic evaluation; this speaks
to continued synthesis, vision and policy recommendations and adjustments. [2]
They also demonstrate investment analysis methods for realistically assessing the business
case for eHealth as well as what the different financing options could be.


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1.3.23 They demonstrate the business case for new eHealth investment, as follows: -

1.3.24 We are asked to consider whether we are estimating the benefits as well as the real costs
attached to eHealth implementation and whether we are adjusting for our optimism bias.
Do we include sensitivity analyses in our process of planning and evaluation? [2]
1.3.25 When ESTIMATING THE BENEFITS, they point us in the direction of a range of metrics: * Quality
* Access – spatial and social inclusion * Overall economic efficiency gains * Appropriate
treatment * Reductions in errors * Avoidance of unnecessary patient visits and examinations *
Reducing polypharmacy[3] * Quality control in general. [2]
1.3.26 We are further asked to consider whether we assign monetary values to the benefits – and
do we then use actual prices and/or proxies?
1.3.27 Do we consider time savings versus the cost of the full-time equivalents, before eHealth? Do
we consider the Time Value of Money, Present Value and Discounted Cash Flows?
1.3.28 We are also pointed to the Markov Chain Approach, which lays the foundation for the
creation of economic simulation models. [2]
1.3.29 What is most definitely required in the design, piloting, ideation and implementation of
eHealth strategies are: flexibility, clinical leadership, risk management, solutions tweaking
because eHealth is not an exact science and lastly, deep pockets and lots of patience.


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[2]

1.3.30 In summary: eHealth should be crucial to improving healthcare and ensuring quality of care
as well as the continuum of care.
1.3.31 It should be viewed as an investment, rather than a cost. Non-financial impacts of eHealth
should also be measured in order to make informed decisions – which includes finance
deployment.
1.3.32 There is perhaps room to look at reimbursement mechanisms – this may be more difficult
within the public health system, but is nonetheless an issue that should be investigated.
1.3.33 A summary of the potential benefits of e-Health: * Access * Quality Improvement * Quality of
Life * Patient safety * Save time * Save costs * Modernise healthcare delivery * Improve
efficiency of healthcare delivery * Secure transfer of patient information * Reducing the
carbon footprint of healthcare.
1.3.34 The Chair opened the floor for discussion and debate: 09:00-11:30


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1.4 PANEL AND OPEN FLOOR DEBATE/ISSUES RAISED/DISCUSSION POINTS
1.4.1

ACKNOWLEDGEMENTS

I did my best to record all delegates who participated and provided inputs to the discussions – but in
the first instance, acknowledge all who made the time to attend, to provide inputs during comfort
breaks, make new connections, share information and network – and I apologise if I have left anyone
out in respect of what I was able to record in respect of specific delegates who provided questions,
input and information during Session One:
In no specific order: * Rosemary – MRC * Simon – PWC * Minister Makoae – Lesotho * Dr Ivan Bromfield –
City of Cape Town * Marago – Lesotho DOH * Prof. Van Greenen – Nelson Mandela University * Aphiwe
– WCDOH * Bakang – OFS DOH * Theunis Hurter – Nova * Ethel – Stellenbosch University Nursing Faculty *
Alan – Video streaming * Paul Davis * Trish – Datacentrix * Bernard – SITA * Dr Solly Lison – Qualicare * Dr
Craig Fredericks – GSM Global * Makago Msidi – Di-Data * Etienne Dreyer – PWC * Cynthia – Botswana
Health Informatics *
1.4.2

POINTS RAISED AND DISCUSSED

1.4.2.1 The South African National eHealth strategy has been published and speaks to partnerships
and collaboration. It is felt that there is enough global and local research available so as to
implement sustainable eHealth solutions. [4]
1.4.2.2 There are strong institutions, such as the Medical Research Council [MRC], SAHIA, SATMA and
others – who are and should be working together more closely to establish standards.
1.4.2.3 There is most definitely a requirement for a National eHealth Standards Board.
1.4.2.4 There is a sense, from certain quarters, that eHealth has become “lost in complexity” and
that there are no definitive proxies to measure or ways of showing benefits.
1.4.2.5 When implementing eHealth, immense patience and will are required – it could take up to
one generation to tweak and adapt a system; persistence is paramount.
1.4.2.6 Mediocre solutions are sometimes better than have no solution at all – at least one can
improve on a solution – but to improve, there must be „something‟ in place to start with.
1.4.2.7 Mention was made of the Eastern Cape Telemedicine project, which worked via cloud
computing – and how, because of no further budget being allocated, it has ground to a
halt – compromising patients and the healthcare system. From that, the conclusion was
drawn that one has to insulate eHealth projects against political change and plan for
sustainability over the mid and longer terms.
1.4.2.8 The fundamental problem is the healthcare system and health itself – not eHealth on its own.
1.4.2.9 According to Simon Samaha – there are a range of eHealth solutions and it not one industry.
He goes on to describe 3 distinct areas of health: 1. Wellness and health –which he feels sits
more in the retail space and has to with patient/consumer behavioural
changes/modification. 2. Chronic Disease Management. 3. Hospital-based – Diagnostic.
1.4.2.10
Chair: In the South African context with specific reference to the public healthcare
system and then more specifically, the Western Cape Department of Health [WCDOH], the
care pathways have been specified and the referral pathways have been strengthened
over the past 10 years, as part of Vision 2010. This means that 93% of patients
[approximately 17 million patient contacts] are seen at Primary Health sites. It is at these
sites as well as via the 2800 Home Based Care Workers [ who are responsible for another
approximately 4 million patient contacts], as well as in partnership with Non-Governmental
Organisations [ NGO‟s] and the private sector, that health and wellness education is at
present, to some degree, happening.[5]

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1.4.2.11








In its Draft Discussion Document, 2020 – a Vision for Healthcare in the Western Cape [6],
WCDOH deals with a range of issues:
It looks at the case for change – and concludes that the compelling motivation for change
includes changes in provincial demography, socio-economic determinants of ill health and the
burden of disease [BOD], advances in technology and global, national and provincial policy
environments that are in the process of change.
Sustaining existing good practice and improving in other areas, are seen as key to becoming a
world-class health organisation and provider. The focus will be on key priorities and the most
cost-effective interventions, given the limited resources available.
Planning for Vision 2020 does include policy frameworks, such as the „green paper‟ on the
National Health Insurance [NHI], the national Human Resources for Health framework and the
provincial Strategic Objective 4 – Improving Wellness. [The purview of wellness falls mostly
outside that of the WCDOH and so a whole-of-government and whole-of-society approach and
interventions are assumed so as to create future generations that are well and healthy.]
WCDOH will focus on prevention and the downstream promotion within the health service
delivery platform – this is an important conceptual shift to take note of.
Seven [7] principles are proffered to guide the 2020 Strategy: 1. Patient-centred quality of care.
2. A move towards an outcomes-based approach. 3. The retention of a Primary Health Care
philosophy. 4. Strengthening of the District Health Services Model. 5. Equity. 6. Affordability. 7.
Building Strategic Partnerships.[6]

[6]

[Source: 2020 – A vision for Health Care in the Western Cape]

1.4.2.12

Simon continues, by pointing out that the solution must be taken to where the problem
actually is – and that it must be understood that eHealth can be key n value creation within
the healthcare system.
1.4.2.13
Optimised resource allocation could reduce existing waste within the healthcare system
by up to 30%.
1.4.2.14
The Honourable Deputy Minister of Health in Lesotho shared the fact there are elements
of eHealth in Lesotho, but that for things to move forward and be sustainable, government
commitment and policies are required to be put in place.
1.4.2.15
She also spoke to the changing of mindsets within the healthcare system as a whole –
also on provider side.

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1.4.2.16

She mentions that there was an upgrade and at attempt at instituting an eHealth patient
record system, that this was done via donor funding and so after the donor has exited, the
equipment is there, but not being used at all – because there was no sustainability planning.
1.4.2.17
Dr Ivan Bromfield pointed out that in the Cape Metro region and WCDOH there is a basic
eHealth system or platform – he raised his concern that providers try to „ sell products into the
system‟, rather than getting back to basics, understanding where the gaps are and
partnering towards finding solutions to plug the specific gaps.
1.4.2.18
Marago from Lesotho Department of Health [LDOH], felt that there has to be a robust
framework so as to enable clear cost-benefit analysis of eHealth systems.
1.4.2.19
She also expressed the concern that is universal – capacity of healthcare professionals to
firstly, design eHealth systems and secondly, to work within such a system. Training of
eHealth professionals is evidently offered in KZN, but the sector should be looking at what is
required so as to structure qualifications within the eHealth space.
1.4.2.20
Prof Van Greenen [Nelson Mandela University] pointed out that a national survey of
MHealth and Telehealth was done – to establish what is wrong with eHealth in South Africa?
The question asked was: Is the technology inefficient? The conclusion from the survey is that
a great many health departments and suppliers are coming at eHealth from a „technology
push‟ perspective, rather than being patient-centred and designing for the patient and the
desired outcomes.
1.4.2.21
Aphiwe [WCDOH] highlighted the need for effective and well-planned change
management and issues related to basic computer skills; this has given rise to the action
point related to doing a national baseline survey in respect of levels of computer literacy of
healthcare professionals within the system – so as to inform a training and implementation
plan. Aphiwe again reiterated that an integrated approach is required.
1.4.2.22
Key decision-makers within government must be convinced about the value of ICT in
general and then eHealth specifically.
1.4.2.23
There is no specific budget allocation for eHealth for provinces. This is echoed within the
South African eHealth Strategy document. [4]
1.4.2.24
Chair: Within the SA eHealth Strategy [4] mention is made that provinces and
municipalities have to budget for eHealth – there is no specific budget within National
Department of Health for the implementation of eHealth systems. In the opinion of the Chair,
this status quo will have to change and specific budget allocations, over a phased number
of years, will have to be set aside, once the norms, standards and Enterprise Architecture are
in place. Without a separate and dedicated budget or financing strategy, it will be
extremely difficult to implement a coherent eHealth strategy and platform on a national
basis.
1.4.2.25
Theunis Hurter from Nova highlighted the success of the Anti-Retroviral [ARV] patient
record; Nova has worked with government to put this system in place. He indicated that
when developing the platform, they gained an understanding of the various healthcare
settings with SA and also, what would stop an ARV system from working – and then designed
and implemented a system that is practical and operationally implementable.
1.4.2.26
Chair: Expanded on the National Tiered Strategy for ART Monitoring [4] and shared the 3
tiered approach that NOVA had managed to implement within the SA Healthcare system:
Tier 1: ART Register: Paper-based – at facilities with no electricity, no computers and less
than 500 patients. Tier 2: Electronic Register: TIER. Net – facilities with regular electricity and
computers, but no network infrastructure and between 500 and 2000 patients. Tier 3: EMR
System – SMARTER – at facilities with network infrastructure and more than 2000 patients.
Information is still collated and cascaded upwards into a central repository. This is an
example of designing for the unique idiosyncrasies‟ of the South African and African
healthcare context.

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1.4.2.27

Ethel from Stellenbosch University, Nursing Department, pointed out that when she visited
and worked in the United States in the 1990‟s, nurses were already using eHealth systems and
it was second nature.
1.4.2.28
She furthermore pointed out that the new generation of healthcare professionals who
are coming into the healthcare system, are what is known as „ digital natives‟ –
“A digital native is a person who was born during or after the general introduction of digital
technologies and through interacting with digital technology from an early age, has a greater
understanding of its concepts. Alternatively, this term can describe people born during or after
the latter 1960s, as the Digital Age began at that time; but in most cases, the term focuses on
people who grew up with the technology that became prevalent in the latter part of the 20th
century and continues to evolve today.
Other discourse identifies a digital native as a person who understands the value of digital
technology and uses this to seek out opportunities for implementing it with a view to make an
impact.” [7]
These “digital natives” were most born after 1985 – and so there is a tension between these multiplatform, digital savvy generation and the digital immigrants – those of us who were born before
the existence and advent of digital technology and who, at best, have managed to adopt use
of certain technologies into our life, to some extent.
1.4.2.29

Ethel goes further and postulates that apart from the potential benefits and efficiencies
that eHealth brings into the healthcare system, it is becoming vital to have the latest
technologies available so as to attract and retain young talent. In her opinion, eHealth will
support the system in general and can be designed to be user-friendly.

1.4.2.30

We are again reminded that there are a plethora of technology solutions – video
streaming was mentioned specifically – but that these are at best “ islands of systems”, which
is one of the issues that needs to be resolved. The industry has to start working together so
that there is a continuum of technology.

1.4.2.31

The question was asked whether one could not allow the system to build itself – given the
range of technologies available.

1.4.2.32

It was also suggested that an eHealth system or platform could be an “enforcer of
compliance” within the healthcare system – nearly as the conscience of the system as a
whole. This is based on the notion that “The system is King” and all will work with it – full stop.

1.4.2.33

It was pointed out that the adoption of new technology platforms in smaller
organisations are far less complex – the CEO has to adopt a change in style – from firstly
achieving consensus of which system would be appropriate, then putting a directive in
place and thereafter, become autocratic in respect of the implementation of the system.
At a National Health level, such a process would be very different and far more complex.

1.4.2.34

Trish from DataCentrix started off by stating that she had been involved in the eHealth
space, conferences, workshops and workgroups for the past 7 years – and that she felt that
there was no significant change or forward movement. This is why DataCentrix decided to
“take the Nike approach and just do it.”

1.4.2.35

WCDOH and DataCentrix worked together to understand all of the limitations, capacities
and requirements and desired outcomes. The secret to the success of the PHCIS system
[which has recently won an international award] relates to the open, honest relationship
between the provider and WCDOH, as well to content lifecycle management, the fact that
they used a web-based patient record – which pharmacists could also access.


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1.4.2.36

The system is ICD10 enabled and is HL7 integrated.

1.4.2.37

HL7 also known as Health Level Seven is a non-profit organisation involved in the
development of international healthcare informatics interoperability standards. HL7 and its
members provide a framework and related standards for the exchange, integration, sharing
and retrieval of electronic health information. There is a 2.x version of standards, which
supports clinical practice and management, delivery and evaluation of health services –
and are the most commonly used globally.[8]

1.4.2.38

WCDOH and DataCentrix analysed the environment, identified what was most needed
so that the eHealth platform would be patient-centric and then designed and allowed the
system to evolve over time. This was about keeping the patient at the centre and putting
personal feelings or agendas aside.

1.4.2.39

Dr Lisson from Qualicare pointed out that they, as a General Practitioner network [600
members all over the province] were not aware of the PHCIS and that it would be very useful
to understand the system, so that private GP could make appropriate referrals and even
have access to the system so as to make referral notes on the system.

1.4.2.40

Rosemary Foster [MRC] pointed to the “dark side” of eHealth. As a specialist within the
eHealth space, she is not in favour of allowing an eHealth system to develop “organically.” It
is her contention that allowing for such a process would do more harm than good.
Enterprise Architecture is required as the basis of departure.

1.4.2.41

She furthermore indicated that there were very few problems related to the adoption
and use of new technology, but that because of the many “false starts” of the past, there
was of course some disillusionment. The implementation of an eHealth system, in line with
the National eHealth strategy MUST therefore NOT be fragmented.

1.4.2.42

Dr Craig Fredericks, GSM Global [ The platform that enables all mobile communications
globally] pointed out that there are already best practice models in place and made
mention of the use of mobile and ICT to train 35 000 Community Healthcare workers in Bihar,
India. He felt strongly that the implementation of eHealth could be fast-tracked by drawing
from existing models and best practice and specifically, the transferability related to
technologies that are being used in other developing countries.

1.4.2.43

The concept of “TeleNurse” access in more rural settings would be a huge benefit
flowing from eHealth.

1.4.2.44

Makago Msidi from Di-Data spoke about the frustration that she has noticed in
healthcare workers, with specific reference to Limpopo province, where she is from. She
believes that eHealth would help to re-ignite these healthcare workers, by making the
process of care swifter and more practical.

1.4.2.45
1.4.2.46

In her opinion, building a robust business case for eHealth is essential.
Emphasis was also put on the process of registering patients onto an e-patient system – it
was agreed that there has to be an implementation plan around this aspect, so as not to
create more frustration at facilities‟ level, where patients are already exposed to long
queues, waiting periods and other inefficacies. It was suggested that there could perhaps
be a timeframe for voluntary registration at multiple points.

The session ended at 11:30. The content of the discussion has been pulled into the Action points
contained within this document.

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2.

SESSION TWO: FINANCIAL ASPECTS OF IMPLEMENTING EHEALTH AND HEALTH IT PROJECTS

2.1 WORKGROUP OUTLINE/DIRECTIVES
2.1.1

With the increased use of electronic medical records, what technology can be used to
ensure efficiency?

2.1.2

Understanding Cloud Computing – How can increasing flexibility reduce costs in urban
hospitals and rural areas?

2.1.3

Data Security – Ensuring the Increased Use of IT in healthcare does not affect security of
patient information.

2.1.4

Business Intelligence Software – Making the most of information gained from EMR‟s.

2.1.5

Productive Efficiency, Costs and Quality across National Health Systems.

2.1.6

Methods of containing costs.

2.1.7

Cost-effective organisation of hospitals.

2.2 PANELLISTS
2.2.1

.Chair: Amanda Brinkmann – Indigo Business Consulting & Advisor to the Minister of Health as
well as Leader of Government Business: Western Cape Government. Head: Strategic
Partnerships: Western Cape Government [ Last effective day of tenure with WCGOV]
2.2.2 Dr Simon Samaha – Physician Leader in Europe, Middle East and Africa – PWC
2.2.3 Trish Dicks – Strategic Account Manager: ECM: Public Sector – Datacentrix
2.2.4 Deputy Minister Makoae – Lesotho Department of Health
2.2.5 Aphiwe Mazambo – Health ICT – Western Cape Department of Health
2.2.6 Bakang Oliphant – Senior Manager Strategic Planning, Monitoring and Evaluation – Free
State Department of Health
2.2.7 Daniel Jaganath – Snr Account Manager BT Global Services
2.2.8 Marius Conradie – e/MHealth – Vodacom
2.2.9 Riaan van Tonder – Business Development Manager: Solutions: Philips Healthcare
2.2.10 Neil Jordan – Worldwide GM – Health Industry: Microsoft
2.2.11 Francois Pierre De Villiers – Snr Manager – Financial Planning OFS Health
2.3 SETTING THE SCENE AND CREATING CONTEXT – AMANDA BRINMANN – CHAIR
2.3.1
2.3.2
2.3.3

2.3.4

According to a KPMG report [9], Electronic Health Record [EHR] implementation costs are still
generally seen as being far too high.
According to a survey done by KPMG, mostly in developed settings, more than 50% of
respondents, who were already halfway in the process of eHealth implementation, felt
uncomfortable with the costs related to implementation.
One of the outcomes of the research study clearly shows that healthcare executives
miscalculate the real costs of HER. There is a tendency to under-estimate the impact and
effort required to fully implement HER and the magnitude of the process is not fully
understood – and therefore not planned and costed for.
In the United States, the Health Insurance Portability and Accountability Act [HIPAA] compels
all medical institutions and practitioners to maintain and store terabytes of data [9] – have we
and are we considering similar provisions in South Africa – and do we understand the
implications from an ICT infrastructure perspective?


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2.3.5
2.3.6
2.3.7
2.3.8

2.3.9

2.3.10

2.3.11

2.3.12
2.3.13

2.3.14
2.3.15
2.3.16
2.3.17
2.3.18
2.3.19

There is a huge shortage of skilled healthcare IT professionals – do we understand the impact
and how are we planning to capacitate the healthcare system with the necessary skills to
manage eHealth strategies and implementation plans?
Is it possible for us to customise, cheap, off-the-shelf platforms, rather than having to design
whole new systems? Do we understand all that is „out there‟ on open source and freeware
platforms?
What are all of the financing options for eHealth – what about vendor/leasing contracts,
where the risk is carried by all of the partners?
Cost and Return on Investment – ROI – are recurring themes – how do we measure these
issues and how do we compensate for the inevitable lost productivity during implementation
+ the additional staff or maintenance costs required? [ As with LEAN or any other change
management process, it is widely known that „ things become worse, before they become
better‟ during the transitional, implementation phases]
The National Health System [NHS] in the United Kingdom, has partnered with the MRC, and
has created four national eHealth research centres. This has been done based on the
understanding that the co-ordination and analysis of huge amounts of information, with the
intent to design better treatment protocols, improve drug safety and optimise resources, is
an extremely complex and difficult task. No one organisation can achieve these outcomes
on its own.
This project will combine the NHS patient health records with other research data, social and
clinical data so that a fuller picture of each individual is formed – so as to move towards true
patient-centricity. Is this something that we should build in at inception of an eHealth
platform in SA – overlaying Home Affairs and other databases and creating individual profiles
of every South African – beyond just their health status?
Cloud computing: - this is hardware and software available over the Internet. Central to
using cloud computing services is the notion of entrusting remote services with users‟ data,
software and computation. There are various service offerings in the cloud: * Infrastructure
as service * Platform as service * Storage as service * Security as service and so on.
The end user requires a web browser, light weight desktop [thin client] of mobile device to
work in the cloud.
Cloud computing allows for economies of scale – cost sharing and savings – and essentially
amounts to being converged infrastructure and shared services. It furthermore has the
following potential benefits: * Agility * Cost savings * Device and location independent *
Reliability * Scalability * Elasticity * Security – this seems like an option that requires deeper
investigation and a policy decision within the eHealth context.
In their research article titled: The Economics of eHealth and mHealth [10], the authors point
out that there is currently no global consensus about what Productive Efficiencies actually
mean and how it should be measured.
There is no consensus on what constitutes efficiency, how to measure it and what actions
should then be taken to improve efficiencies.
There is a very definite need for a universal framework, definition of terms, uniform sampling
methods and the recognition and there not necessarily direct causality between cost and
quality in the healthcare system in general.
A decision must be taken about which elements of healthcare we value – those must be
agreed and measurement metrics put in place accordingly.
The key economic and financial questions to be answered in developing countries are
directly related to the ability to measure outcomes and ROI.
There is growing evidence of the potential benefits of eHealth and mHealth – but little or no
research available of the economic impact of such investments in lower and middle-income
countries. [10]


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2.3.20 It is felt that there is insufficient data/research in developing country settings, to reach
“generalizable” conclusions so as to guide investment decisions. [10]
2.3.21 The authors call for a roadmap to be created in respect of how research could be used as a
tool to establish the true cost and benefits of eHealth systems. [10]
2.3.22 In general, we HAVE to plan, cost out and understand the potential impact of eHealth on
healthcare costs in general – what will the short term increase in costs be and how do we
measure these short-term costs/investments against the long term benefits and how are we
apportioning value throughout the delivery chain?
2.3.23 Are there low-cost eHealth technologies that are suitable to low resource settings?
2.3.24 In respect of the Drivers of costs, we need to consider and plan for the following: * Upfront
investment in infrastructure - as a fixed or variable cost * Cost of connectivity and
telecommunications * Economies of scale – can it be achieved and how? * PPP‟s – not
necessarily in the traditional format – more in line with partnering related to end-to-end
systems, where risk and responsibilities are shared * Clinical as well as social outcomes – we
have to create reliable conversion factors.
2.3.25 In conclusion – there is a need build an evidence-base, research case, economic studies
and a framework within which to function – to which all role players should continue and
„ subscribe‟.
2.3.26 The Chair opened up the discussion – by asking each of the panellists to „ state their
position‟, where they feel they could contribute and then opened the debate for the floor.
Session time: 11:30-13:00
2.4 PANEL AND OPEN FLOOR DEBATE/ISSUES RAISED/DISCUSSION POINTS
2.4.1

ACKNOWLEDGEMENTS

I did my best to record all delegates who participated and provided inputs to the discussions – but in
the first instance, acknowledge all who made the time to attend, to provide inputs during comfort
breaks, make new connections, share information and network – and I apologise if I have left anyone
out in respect of what I was able to record in respect of specific delegates who provided questions,
input and information during Session Two:
In no specific order: * Rosemary – MRC * Simon – PWC * Minister Makoae – Lesotho * Marago – Lesotho
DOH * Prof. Van Greenen – Nelson Mandela University * Aphiwe – WCDOH * Bakang – OFS DOH * Riaan
Van Tonder * Ethel – Stellenbosch University Nursing Faculty * Trish – Datacentrix * Bernard – SITA * Dr
Solly Lison – Qualicare * Dr Craig Fredericks – GSM Global * Makago Msidi – Di-Data * Etienne Dreyer –
PWC * Cynthia – Botswana Health Informatics * Daniel Jaganath – BT Global * Prof Jutz Marks * Lionel
Benting – ICT – Department of the Premier – WCGOV * Ian de Vega – Health ICT: WCDOH * Amano
Majobakwana – Ghana * Pearl – SA Legal Association
2.4.2

POINTS RAISED AND DISCUSSED

2.4.2.1 Marius from Vodacom opened the discussion by agreeing that the cost and complexity of
eHealth implementation is most definitely under-estimated. In his opinion, eHealth is
reaching a tipping point, which will nearly force the 3 industries or component parts to come
together:


Page 16

ICT – EHEALTH +
MHEALTH – DECISION
SUPPORT AND PATIENT
CENTRED, QUALITY
HEALTH OUTCOMES ENABLER

HEALTH FACILITIES AND
PROFESSIONALS –
PRIVATE AND PUBLIC
SECTORS – DIAGNOSE
AND TREAT – BASED ON
EHEALTH AS ENABLER

ELECTRONIC HARDWARE +
DIAGNOSTIC EQUIPMENT –
LINKED TO MOBILE – LOWER
COST HARDWARE AND
EQUIPMENT

CONVERGENCE AROUND 3 LAYERS:
COMMUNICATIONS, INFORMATION, MANAGEMENT – INTERCHANGE OF KNOWLEDGE
TO ADD VALUE – THIS „RELATIONSHIP‟ MUST BE
CONFIGURED AND A BASIC TOOLKIT DEVELOPED, WHICH
COULD BE CUSTOMISED FOR DIFFERENT SETTINGS

2.4.2.2 Riaan van Tonder – Philips Healthcare, stated that one has to look at the national health
plan and determine what would be “appropriate technology” for the specific market.
2.4.2.3 He wondered, out loud, whether there is a true and real will to partner, that such partnerships
are ill-defined and raised concerns regarding risk sharing, the cost of leasing equipment and
the fears of providers related to dependable payment – given the less-than-good financial
track record of the majority of health departments in South Africa. Without financial security,
eHealth systems could be „switched off‟ in the event that payment is stopped. This is a risk
that needs to be mitigated and securitised.
2.4.2.4 Trish from DataCentrix focused on the issue of African-centricity – rather than importing
solutions from abroad, custom designing and creating knowledge in Africa for Africa.
2.4.2.5 In her opinion, the cost-benefit is “easy to measure – by asking, what is the level of service as
experienced by the patient.”
2.4.2.6 She furthermore stressed the fact that to design and implement successful eHealth systems,
planning and budgeting with your partners are essential – this is what has made the
DataCentrix/WCDOH partnership work.
2.4.2.7 There continues to be a strict and rigorous programme management and all deliverables
have been clearly defined up-front.
2.4.2.8 She also reminded all delegates that, “if you can‟t explain it in simple terms, then you don‟t
understand what you‟re doing or what it is.”
2.4.2.9 Minister Makoae – Lesotho Department of Health felt strongly that the private sector must be
more empowered by government to do the things that governments are not good at – she
felt that eHealth is one of the areas where the private sector should play the leading role.

Page 17

2.4.2.10
2.4.2.11

Simon from PWC reminded us that health and healthcare are indeed local issues.
In his opinion, ObamaCare is not causing any to change materially within the United
States, with reference to the eHealth systems requirements and incentives offered by the US
Government. Some hospitals and health facilities are not prepared to make the investment
and see no value, besides the fact that the government incentives do not come close to
covering the actual cost of implementation.
2.4.2.12
In other cases, health facilities and professionals simply view eHealth as a “must have” –
and rather than expecting a direct ROI, view eHealth as part of the cost of doing business
and as a driver of mid- to long-term efficiencies and savings.
2.4.2.13
He also briefly spoke about the EPIC eHealth platform – where the brand owners do a
due diligence on the clients they are prepared to work with and only then, will they partner
and implement their system.
2.4.2.14
Daniel Jaganath – BT Health – spoke to the fact that BT Health has been involved in
operationally functioning health systems for quite some time. There is Framework – modelled
on the work done for the NHS – and that there are possibilities to partner with BT Health so
that the mistakes that were made during the genesis of their eHealth implementation
process, are not repeated in South Africa and Africa. He essentially recommended that the
existing Intellectual Property [IP] should be leveraged, so that there is no duplication.
2.4.2.15
He agreed that there will always be a need for customisation, but that the basics can be
drawn from best practice.
2.4.2.16
He also spoke to the Virtualisation environment, with specific reference to Cloud
Computing and the integration with GSM networks – and indicated that technology to
deliver patient care exists, via an entry network, spine or health cloud – and that the
framework or platform is built off the spine.
2.4.2.17
Aphiwe – WCDOH – reiterated the fact that patient-centricity remains at the heart of
how WCDOH will be moving forward in strengthening the eHealth platform. He invited all
delegates, but specifically the Minister from Lesotho, to visit the Khayelitsha Hospital, so as to
experience, first-hand, the impact of the best practice in design, construction, lay-out,
structuring of services and efficiencies related to a comprehensive eHealth system that is
functioning.
2.4.2.18
He felt that moving to Cloud computing is a very real and practical option in eHealth.
He also indicated that the roll-out of ECM could be made cost-effective, using cost-sharing
models, which combines outsourcing with the use of internal staffing.
2.4.2.19
Bakang – OFS DOH – stated that in his opinion in the healthcare system, there are 2
elements: 1. Those whom render patient care 2. Everything and everyone providing support
to those that render care.
2.4.2.20
He therefore felt that eHealth must “fit into” the system so as to mitigate against the costs
and inefficiencies related to the current paper-based system and that it must be viewed as
an enabler of improved healthcare delivery.
2.4.2.21
Prof Van Greenen – Nelson Mandela University – confirmed that they have been working
with the CSIR and DOH to create standards for inter-operability. There is however a concern
about the isolated manner in which various projects, programmes and issues are being dealt
with – this echoes the sentiments expressed by a great many of the delegates and is
furthermore supported by global research and academic reviews.
2.4.2.22
Prof Jutz Marks discussed an application called “Fear Fighter” which assists in the
treatment of anxiety disorders. According to Prof Marks, we are at the place in time where it
is all about “the birth of new solutions.”
2.4.2.23
He added that when looking at cost-benefits and cost containment, it becomes sensible
to partner with the private sector, with specific reference to risk sharing models and
technical support.

Page 18

2.4.2.24

He pointed the delegates to the very successful Lesotho PPP model, where an honest,
independent, intermediary or broker was used to facilitate the process and to ensure that
there was no political interference, corruption and that the project was rolled out as
effectively and efficiently as possible.
2.4.2.25
Lionel Benting – DOTP WCDOH – pointed out that unfortunately, not all browsers are
equal. This is however not an insurmountable problem. He also indicated that a thin client
solution was currently being rolled out in the province and that cloud computing is most
definitely a viable option.
2.4.2.26
Amano Majobakwana from Ghana stated that eHealth has not been leveraged in
Ghana at all, due to financial constraints.
2.4.2.27
She spoke to donor funding that led to a Teleconsultation pilot project – but that, in her
opinion, one starts suffering from what she called, “ pilotitus” after a while – and that
sustainability remains one of the central issues with these projects. Once donors withdraw,
the projects fall flat.
2.4.2.28
Pearl from the SA Legal Association raised question around patient confidentiality and
safety as well as the amount of information that would need to be captured. She
approached this from the medico-legal perspective, so as to understand the implications of
eHealth.
2.4.2.29
The Chair discussed the variety of ways in which patient information can be captured
rapidly – from using digi-formats of documents with digipens, to touchscreen technology and
in some instances, there might be a requirement for information to be manually captured.
Whilst this may take time when the patient has to be registered, the once off inconvenience
should be cancelled out by the convenience and benefits in the longer term.
2.4.2.30
Simon from PWC pointed out that “there is nothing LESS secure than paper-based charts”
– and that electronic security platforms and systems have been proven as completely
secure and safe.
2.4.2.31
He ended off the session by leaving the delegates with the realistic statistics – that they
should allow for at least 25% decrease in productivity within the first 6 months of eHealth
implementation, but that it is worth it in the long term, when the system starts to flow and the
benefits start accruing.
The session ended at 13:00. The content of the discussion has been pulled into the Action points
contained within this document.
3.

GLOBAL TRENDS IN MOBILE USAGE AND MOBILE HEALTH – ADDITIONAL BRIEFING: CHAIR

3.1 DIY HEALTH – GLOBAL TREND 2012
In 2012, Trendwatching [11] looked at the emergence of DIY Health care and set the tone of their report
as follows: “ DIY goes „ good for you‟ in 2012: novel apps and devices will increasingly let consumers
discreetly track and manage their health by themselves.”
They predicted that the DIY trend in Health would not slow down during 2012. The report spoke about
the two kinds of DIY health: 1. The kind that most consumer HATE and 2. The kinds that they love. It was
predicted that the latter category would be driven by innovation driven by technology and very
importantly, by the need of the consumer to be in control.
At the time of issuing the report, there were 9000 mobile health applications [including nearly 1500
cardio fitness apps, over 1300 diet apps, over 1000 stress and relaxation apps, over 650 women‟s health
apps and by mid-2012, the number of apps was expected to reach 13 000. [13]

Page 19

Countless new apps and devices are actively targeting consumers who are keen on preventing,
examining, improving, monitoring and managing their health. Mobile health and these kinds of
applications, where the patient or consumer takes an active role in their health status, of course also
means that there is more than likely a reduction in the number of visits to medical professionals and
facilities and these applications provide more convenient and accessible ways for a doctor to “keep a
remote eye” on troublesome conditions and changes in patient health status. [11]
EXAMPLES OF TECHNOLOGIES, APPLICATIONS AND DEVICES:.



Released in November 2011, Jawbone‟s Up is a wristband personal tracking device that tracks a
user‟s moving, eating and sleeping patterns. The device syncs with an iPhone app, and users
can set the device to vibrate when they have been inactive for a period, compete against
friends and even earn real life rewards for completing activity challenges.



Pain Free Back, an interactive back pain relief product, lets users enter specific data as they‟re
taken on a guided discovery about their back pain. Exercise solutions are offered afterwards.


Page 20





The Play It Down app enables users to test their hearing. The app offers several interactive
features including 'The Ear Knob' that lets friends compare who can hear the highest
frequencies, and 'The Volume Zone' which measures sound volume in decibels.
The Digifit Ecosystem is a suite of Apple apps designed for those with an active lifestyle. It can
record heart rate, pace, speed and power. Data can also be uploaded to and managed via
training sites such as Training Peaks and New Leaf.


Page 21



Withings' Blood Pressure Monitor plugs into an iPad, iPhone or iPod Touch and takes the user‟s
blood pressure. Data can be sent directly to a doctor or published (confidentially) on the Web.



Skin Scan is an app which allows users to scan and monitor moles over time, with the aim of
preventing malignant skin cancers. The app tells users if a visit to their doctor or dermatologist is
advisable.



Lifelens has created a smartphone app to diagnose malaria. The app can analyse a magnified
image of a drop of blood (captured via a simple finger prick) and identify malarial parasites.

As mentioned, these are a small selection of examples of the rise of mobile health technology and
applications. Things start becoming rather more interesting, when looking at the 10 top consumer
trends predicted for 2013. [12]
3.2 CONSUMER/PATIENT TRENDS – 2013 – TO KEEP A KEEN EYE ON
In the report titled, 10 Top Consumer Trends predicted for 2013 [12], the tone is set by stating that the
next 12 months will be the perfect storm of necessity combined with opportunity. The global economy
has been remapped, new technologies are emerging, or the use of “old” technologies applied in new
ways and new business models are emerging. I have attached a full copy of the report, separate to this

Page 22

briefing document – for the purposes of mobile and eHealth; the following predicted trends should be
of interest and value in the eHealth space:
3.2.1

TREND 3: MOBILE MOMENTS

“Lifestyle multi-if-not-hyper-tasking: why micro-convenience, mini-experiences and digital snacks will
rule in 2013” [12]
This trend predicts that consumers will be looking to their mobile devices to maximise every moment in
their life. It embraces the notion of lifestyle multi and hyper-tasking.
EXAMPLES OF MOBILE MOMENT TRENDS, APPLICATIONS AND PROJECTS:


Page 23

3.2.2

TREND 5: APPSCRIPTIONS

“digital technologies are the new medicine”
This trend is premised on the fact that doctors and physicians are turning to health applications and
services to improve healthcare delivery. There has been a huge rise in the use of DIY healthcare
applications since 2012. As predicted in 2011, there are now, at the end of 2012, over 13 000 healthcare
applications in the Apple AppStore alone and so now, the challenge for the patient/customer lies in
finding those applications that are accurate and safe. These are important to patients, as this
concerns their health.
Consumers are therefore turning to medical professionals and medical institutions to certify and curate
mobile health applications and doctors are increasingly „prescribing‟ mobile applications as part of the
course of treatment for the patient.
For health providers, these digital „medicines‟ hold the promise of cost reduction by making consumers
more aware of their health status, improving compliance and treatment adherence as well as having
the ability to monitor the patient and pick up early warning signals.

Page 24

The under-lying trend remains: Mobile-driven service Delivery
EXAMPLES OF APPLICATIONS:


Page 25

3.2.3

TREND 7: DATAMYNING

“why consumers want „good‟ data and not „big‟ data”
Data is the new resource and the consumer will start demanding their share of its value. In the past, the
“big data” discussion was focused on the value of consumer data to businesses and brands. Savvy
consumers are now however starting to reverse the flowing, seeking for their own lifestyle data to be put
to good use by brands and companies.
It is predicted that consumers will increasingly expect, if not demand, that brands and companies use
their personal data pro-actively, by offering the consumer assistance, advice on how to improve their
behaviour and/or how to save money. The caveat here is that the consumer wants to feel served, in a
real and personal manner – not watched, as though by some „Big Brother‟.
EXAMPLES OF MOBILE APPS AND PROJECTS:


Page 26


Page 27

4.

IN THE FINAL ANALYSIS: PARTING SHOTS

It is clear that eHealth and mHealth are not a nice-to-have, but rather must-have technologies in order
to improve overall quality of healthcare services delivery, save costs, time and strengthen the health
system. From the actions points, the knowledge that was in the room during the Forum, the plethora of
global research, standards and frameworks that exist, that there is concerted effort required to pull
together one South African and African Body or Organisation, which would act as the central repository
of information and would crowd all of the existing knowledge, information, standards, case studies and
best practice models and create frameworks, policies, enterprise architecture, cost-benefit analysis
models and implementation plans, all of which would be appropriate for the South African and African
context.
My final recommendation is that all of the delegates review the action points, that we reach consensus
on who is prepared to champion specific action points, that we set realistic timelines, given that doing
such work would be over and above the daily duties of such „champions‟ and assemble workgroups to
assist in moving the agenda forward in a practical manner.
If we do not agree on firm action points, outcomes and timelines, we run the risk of following the global
trend, which is to continue research, having on-going talk-shops in isolation of the larger systems view

Page 28

and not actually arriving at the place where we have all of the tools in place to move forward
decisively.
It has been my ABSOLUTE privilege and honour to chair these two panel sessions, to meet new minds, to
reconnect with old friends and to be a small cog in the much larger engine that is driving the
ICT/technology/eHealth agenda forward.
In my opinion, we have the opportunity to take hands and to fast-track the process of using technology
to empower growth and developmental outcomes in our country and region.
Thank you again to all who attended and participated. I have learnt much – and that always makes
me happy.
Sincerely and with warm regards
AMANDA BRINKMANN
DIRECTOR: INDIGO BUSINESS, MARKETING, MANAGEMENT CONSULTING

DEFINING, UNTANGLING AND SOLVING „THE MESS‟ *
 “ A mess is the future implicit in the present behaviour of the system”


Page 29

REFERENCES: AFRICAN E-HEALTH ECONOMICS FORUM – PANELS ONE AND TWO
[1] Berman, P; Bitran, R. May 2011. Health System Analysis for Better Health System Strengthening. World
Bank Report . Health, Nutrition and Population Discussion Document. Appendix A: Excerpts
Stroetmann, K, A; Dobrev, A; Jones, T. 3 November 2008. Assessing socio-economic and clinical
benefits from eHealth solutions – approach and evidence. eHealth Planning and Management
Symposium, Kopenhagen.
[2]

Brinkmann, A. November 2012. Concept Proposal: Empirical Pilot Project: Reducing and Managing
the Burden of Disease, Chronic Medications and Improving Patient Quality of Life through a Training
Partnership in Pharmacotherapy: Effecting significant immediate and long-term cost-savings to the
healthcare system. [ Unpublished]
[3]

National Department of Health: South Africa. September 2012. eHealth Strategy South Africa. Full
document appended.
[4]

[5] Western

Cape Department of Health. Annual Performance Plan 2012-2013

[6] Western

Cape Department of Health. November 2011. 2020 – the future of Healthcare in the Western
Cape. A Draft Discussion Document.
[7]

Define: Digital Natives. Wikipedia.org. Accessed November 2012

[8] Define
[9]

Health Level 7: HL7. Wikipedia.org. Accessed November 2012

InformationWeek – Healthcare. July 2012

Schweitzer, J; Synowiec, C. 2012. The Economic of e Health and mHealth. Journal for Health
Communication.
[10]

[11] Trendwatching.

2012. DIY Health – Trend Briefing

[12]

Trendwatching. November 2012. 10 Crucial Consumer Trends 2013. Full summary report attached.

[13]

MobiHealthNews. September 2011. Mobile Health Applications Research report.


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[1]

APPENDIX A: EXCERPTS HAS FOR BETTER HEALTH SYSTEM STRENGTHENING


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African e health economics Forum: Amanda Brikmann Chair: 2 sessions: Context for e-health, notes + actions to move forward: A discussion

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