 |
IAPAC Monthly - Vol. 8, No. 5, May 2002
Patrick Connelly
| I-MED Exchange Evaluation – Sidebar I: Breakthrough |
|
The inaugural “virtual seminar” of I-Med Exchange was a significant event. We waited in anticipation, seated in front of a computer screen at IAPAC’s Southern Africa Regional Office (Johannesburg), poised with our headsets to “bridge a digital divide.” This was an adventure that, by now, had come to feel more and more like navigating a rope bridge across the Limpopo river in a new 4-wheel drive vehicle. It had already been a long journey to this point, filled with metaphorical “obstacles, potholes and diversions.” This made the moment even more tense and memorable, as we sat, counting down the moments to “lift-off.” Finally, and one-by-one, participant names began to appear on the screen, as proof that Francistown was listening, Oudtshoorn had arrived and Tintswalo had tuned in. We waited with baited breath to witness the “birth of a new age,” half expecting to hear crackly transistor voices coming to life. Our fascination with the technology that we had finally tamed, and the novelty of this impressive application enthused the session participants as we “sound-checked” again and again to confirm that we were all virtually there. Along the path, some names disappeared as others appeared. Throughout, some were not to be seen again, while others reappeared after dropping off at certain points. Clearly, this pointed to the fact that some participants were obviously having a difficult time staying connected, as the instability of their “pots” (plain old telephone system) connections let them down. Nonetheless, we persisted. Participants experimented with the interactive tools on the Centra interface. They intuitively marked “checks” and “crosses” to indicate either “yes/OK” or “no/I have a problem,” and raised their virtual hands in order to be passed a microphone icon so that they could make comments in real-time. Surprisingly, and to the pleasure of all, speakers came across as clearly as if they were on a telephone call. This was so much more functional than a teleconference call, and far more fun! For some. Swept away by our satisfaction that the system appeared to be functioning fairly well, a text message soon appeared from one participant, a senior AIDS physician at a government referral hospital who had logged on from Botswana. Evidently he was not receiving the audio feed and his version of the presentation slides were taking forever to load onto his screen. Yet, more than these technical difficulties, his text message to the group read: “Today I saw a patient who is failing his second antiretroviral regimen ... can you advise what the options are?” Glee turned to consternation, as reality checked in. This was the poignant reminder of why I-Med Exchange was necessary. |
Secure the Future (STF), a US$100 million philanthropic initiative of Bristol-Myers Squibb, was launched in May 1999 with a goal of funding innovative HIV care, prevention, and research programs to benefit women and children living with and affected by HIV disease in five southern Africa countries. Within a year, STF funded a number of institutions, including the International Association of Physicians in AIDS Care (IAPAC) to launch a series of innovative programs, among them I-Med Exchange. This pilot IAPAC program aimed to determine whether information technology could provide a means for bringing HIV/ AIDS health education and information support to remotely located physicians and allied health professionals working in STF-targeted countries.
In announcing a US$390,000 grant to IAPAC, Bristol-Myers Squibb Vice Chairman Kenneth Weg classified I-Med Exchange as "a pioneering step in dramatically expanding access to knowledge for the care and support of HIV/AIDS patients in sub-Saharan Africa. This model initiative is an opportunity to bring the benefits of modern medicine and technology to the people of the developing world to improve public health…"
With STF funding, and a subsequent donation of 100 multimedia computers by Compaq Corporation, IAPAC announced I-Med Exchange’s launch in July 2000 at the 13th International AIDS Conference in Durban, South Africa. The one-year pilot program would be directed to physicians and allied health professionals providing HIV/AIDS care in five southern African countries—Botswana, Lesotho, Namibia, South Africa, and Swaziland— each of which was selected because of high HIV prevalence and desperate need for human resource and infrastructure development. In scope and design, I-Med Exchange was to be a pioneering initiative to bring connectivity, remote support, and HIV/AIDS education and information via the Internet to healthcare workers across the five-country region.
Almost two years now to the date since its launch, I-Med Exchange has provided a critical mix of benefits and lessons. These will not only be filtered into the ongoing refinement of the program, but also form the veritable genesis of knowledge surrounding appropriate means of introducing advanced information technologies into limited resource settings on the African continent, and elsewhere, for the purpose of enhancing medical education and knowledge sharing. It is in this spirit of learning, growing, and facing the future in full partnership with our colleagues worldwide, that IAPAC shares its experiences, to date, surrounding I-Med Exchange.
I-Med Exchange proposed to "bridge the digital divide" between the developing world and the developed world for health information, using information technology. IAPAC posited that by providing education and information on HIV/AIDS, physicians would be empowered with knowledge to confront the epidemic. The program would also facilitate bi-directional dialogue among physicians from the various regions and sites of southern Africa and with HIV/AIDS specialists around the world.
The main, formal activity of physicians enrolled in the program would be to participate in interactive online presentations accessed live on the Internet, or viewed as archived seminars either on an I-Med Exchange Web site or CDROM.
During these live presentations, physicians would be encouraged to share their experiences in treatment and care with leading HIV/AIDS experts, and to collaborate to forge partnerships with their colleagues. With Internet capability, physicians would also be able to access the vast resources of the World Wide Web, and would have a multimedia computer with all necessary software and a printer, to use as a resource in their work.
A multinational Curriculum Committee of well-recognized HIV/AIDS thought-leaders was convened to serve as custodian of the educational aspects of the program and to develop the curriculum outline.
An international faculty of presenters from among IAPAC’s worldwide membership base agreed to deliver online seminars based on this curriculum, that included issues from a comprehensive range of HIV/ AIDS treatment, care, and support topics.
One of the stated purposes of I-Med Exchange was to investigate unchartered territory by delivering education to remote areas over the Internet. This pilot program was a way to investigate what implementation challenges need to be addressed if information technology (IT) is to be used as a tool in supporting HIV/AIDS care capacity. Reporting on the lessons learned and problems encountered is an important outcome of the program.
IAPAC conducted a pilot study in a few different settings before proceeding to distribute computers. This was done in order to avoid and correct any problems that might have been encountered. Unfortunately, despite this measure, certain difficulties were only discovered once equipment had already been widely deployed.
| I-MED Exchange Evaluation – Sidebar II: Connectivity in Africa - remaining challenges and recent strides |
|
Telecommunications connectivity has become part of the edifice upon which progress in the developed world depends. In Africa, the low level of prevailing infrastructure in most cases means that the continent will fall even further behind the rest of the world in quality of life indicators unless drastic steps are taken to address the situation. There is no doubt that the communications and information infrastructure in Africa has improved dramatically over the past years. Satellite television, the Internet and cellular phones are now widespread on the continent. But what might have been completely unthinkable a decade ago, is still a dream for the vast majority of Africans—those who do not live in the capital cities and are not part of the privileged few. Access to telephones alone is still extremely scarce. There are only about 14 million telephone lines on the continent—fewer than the number of phones in Manhattan or Tokyo—and if northern Africa and South Africa are not counted, there are only 3 million lines to be shared among the remaining 600 million people. Furthermore, most of the lines are concentrated in urban areas while over 70 percent of the population is rural. As a result, most Africans have never even made a phone call, let alone surfed the web. There are only about 100,000 dial-up Internet accounts for 750 million people (excluding South Africa) and because Internet Service Providers (ISPs) are usually concentrated in the capital cities, even if there is a computer available, it is usually a prohibitively expensive long distance call to the Internet. At the same time, most of the available information on the Internet is oriented towards western and urban populations, with few applications relevant to farmers, natural resource managers, women, youth and rural people on the African continent. Africa’s strategies for accelerating information infra- experistructure development have provided a rich diversity of approaches and a fascinating variety of responses to historical conditions. It is clear that concerted national strategies are being put in place, aimed at addressing these issues. In particular, restructuring of the telecommunication sector is increasingly coming to be seen and appreciated as vital to Information Communication Technology (ICT) development. Many countries have separated postal services from telecommunications and many countries now have a separate regulatory authority. International capital and strategic partners have been obtained by some of the national PTOs but few second operators have been established as yet. Liberalization of the market for value-added services in some countries has resulted in a large number of various types of service providers. There have also been some noteworthy efforts to expand telecommunication infrastructure to rural areas through the institution of Universal Service Obligations and funds for rural communications development. By setting targets for provision of services and connectivity, services have improved and the rate of telephone line rollout has increased. Cellular phone service providers have been licensed in almost all African countries, which has brought network coverage to many rural areas that do not have telephone networks. Internet service providers (ISPs) are establishing their own independent links to the Internet, rather than being forced to go through the incumbent telecommunication operator’s infrastructure. However, Internet access costs will still need to be reduced significantly before a wider spread of the population can make use of these services. Telecom operators can play a vital role in reducing the cost of connection for those who are a long distance call away from the Internet service provider. This is the case, for example, in many Francophone countries where a special local call tariff applies to calls made to the Internet from anywhere in the country. However, even where it is a local call to the Internet provider, local call costs are still relatively high. The extensive use of wireless data services in the few countries that have sanctioned them is worthy of note. Clearly, wireless systems offer a number of advantages that will be increasingly in demand as the need for low-cost, highbandwidth and reliable Internet connectivity becomes more important. Improved public access to telephones, computers and the Internet, especially in rural areas, is clearly of concern to all developing countries, and new telecentre models will be of great interest to policy makers in the near future. Of particular note is the strong trend among small entrepreneurs to expand public phone businesses into mini-telecentres, when combined with an ISP’s free e-mail services. With respect to computer hardware, while import duties on computers in many African countries have come down substantially over the last few years, the continued high level of import taxes on computers in some countries is a barrier to accelerating the computerization process. The liberalization of the broadcasting sector, which has taken place in many countries, has resulted in a significant increase in the number of independent broadcasters. However, while there are some notable community stations in a few countries, the majority of radio and television diversity is still concentrated in the capital cities, with usually only the state broadcaster reaching a wider listener or viewership. Many countries are developing national information and communication planning processes which are being conducted at high levels in government, and involving a broad range of stakeholders. While the impact of individuals who champion the cause of improved infrastructure should not be underestimated, it is also important to note the ongoing support of the international community in assisting many of these initiatives. |
The first task facing project coordinators was to find ways of sensibly distributing donated computer equipment as equitably as possible across the participating countries, while responding most appropriately to identified instances of need in each.
An objective evaluation tool was developed to rank the needs and appropriateness of individual applicants. Ultimately, their enthusiasm to participate in the program was the most important deciding factor, but other criteria included:
In many instances, rank score of need weighed heavily in favor of the applicant being offered equipment to become an I-Med Exchange enrollee. However, this need also reflected the difficulty that could be expected to be encountered in establishing and supporting the IT infrastructure at that site. This subsequently impeded progress since the sites most in need of assistance were found to be least prepared and/or appropriate (from a technical perspective) to receive the donation.
So, while the resulting process did achieve strategic distribution of hardware, this was done without enough consideration for the environment that would be necessary to support the technologies at each chosen site. The deployment process therefore failed to ensure that Internet accessibility could be realistically achieved for all participants, based on their infrastructure and other challenges as described in greater detail, in this report.
On advice from STF, Namibia was eventually excluded as a participating country, since ongoing impediments to STF’s involvement there were inhibiting progress in implementing I-Med Exchange. In the remaining countries (Botswana, Lesotho, South Africa, and Swaziland), IAPAC worked in cooperation with Ministry of Health officials (or with the endorsement and knowledge of the ministries) to identify individual physicians who would be most suitable participants.
As of December 2001, 88 out of the total of 100 computers had been allocated to physicians in four southern African countries:
Of the remaining 100 donated computers, four were used in the establishment of IAPAC’s Southern Africa Regional Office (SARO) to support the program. Another eight could not be used at all, for technical reasons.
Each country had its own requirements for receiving computers, that had to be taken into consideration, and with different bureaucratic procedures needing to be respected in each situation.
Within South Africa, for example, the computer equipment was allocated to individual recipients who agreed to sign a personal loan arrangement, since the procedures for government departments to officially receive donations into their asset register were prohibitive. This has led to difficulty defining who is responsible for the equipment upkeep and for liability in cases of loss or damage. Disputes over ownership have also been encountered, complicated by some participants relocating or changing their area of work.
In comparison, the Swaziland government itself received the equipment as an official donation, and so has taken ownership and control over its allocation and usage. Processing this donation through customs procedures from South Africa created long delay in getting the equipment to recipients, since Swaziland’s government had to undertake lengthy and complex procedures to obtain exemption from importation duties on the computers. The current distribution of I-Med Exchange sites is summarized in Table1.
Many of the sites at the end of this evaluation period are occupied only by individual participants, but IAPAC has been actively restructuring these sites in order to allocate equipment that has not been used optimally, to more appropriate sites. In this reallocation process, preference is being given to sites where the donation of computer equipment is most likely to contribute toward the development of a "telecenter" that is accessible to many more individuals than the single I-Med Exchange subscriber.
The advantages to this approach are the increased influx of resources into local initiatives to serve as a developmental catalyst, and the strengthening of existing infrastructure. The model has yet to be fully implemented or properly tested, and this will be a priority for the immediate continuation phase of I-Med Exchange.
IAPAC-SARO is currently also establishing a regional information and training resource center in Johannesburg. The resource center will serve as the hub of a linked network of smaller peripheral information and training resource sites, supported through I-Med Exchange. Three sites have already been established at public hospitals, and IAPAC hopes to re-deploy a further eight previously distributed computers in this way.
The full technical requirements and resources needed for maintaining and supporting such a widely dispersed network of computers installed at isolated low infrastructure sites, and used by IT-inexperienced health professionals, was entirely underestimated.
To address some of the technical requirements, independent IT consultants were employed in each country to diagnose problems and, to a limited extent, assist with overcoming initial implementation difficulties in the rollout phase of the program.
In Swaziland, a number of computer problems were experienced due to storm damage, lightning strikes, and power surges. Telephone connections were not adequate for consistent dial-up connectivity and were found to be much slower than in South Africa. For a period of time, connections were even completely severed when the telephone company suspended the government’s telephone services over a payment dispute, despite I-Med Exchange sponsoring the costs of the Internet connections. An independent technical audit of connectivity and hardware was commissioned by IAPAC and technology consultants advised replacing all modems as a solution to the poor connectivity.
Participants in Botswana also experienced frustratingly slow Internet connections and the modems supplied were not reliable. Even after replacing these modems with alternative external modems, the stability of basic Internet connections improved, but remained inadequate for participants to access real-time online seminars, which a technical expert ascribed to "routing problems" within the Botswana Telecom system.
In Lesotho, five computers were donated to the Ministry of Health, but have never been connected to the Internet, due to the absence of a suitable internet service provider (ISP) that could be accessed from government facilities. Internet services have only recently become available but the telephone company can only guarantee a 9,600 bps slow connection. New telephone lines are difficult to have installed and Ntabiseng Mabitle, Director of the National AIDS Program, states, "Communication is a real problem. We have only one fax machine in the whole department and only a few computers." Adding to these difficulties, the modems supplied through Compaq’s donation have also been found incompatible with the computer hardware.
South Africa fared much better with connectivity, but was also plagued by incompatible modems installed in the donated computers. Connecting to rural sites was also problematic in this setting.
Making computer hardware available to selected sites that did not have adequate, pre-existing IT was seen as a necessary incentive and means for achieving participation by physicians in I-Med Exchange.
Compaq Corporation (Compaq) donated 100 multimedia computers to be distributed to these sites. Sadly, this benevolence turned out to be fraught with pitfalls. The computers became a source of much difficulty and frustration, severely impeding the program’s implementation. For example, the donated hardware was received from Compaq without CDROM drives (while the Microsoft-based operating system and office utilities were also provided by Compaq on CDROM disks). Internal modems supplied with the computers had also not been installed and costly technical assistance had to be contracted to prepare the computers for distribution. Particularly frustrating, was that these internal modems failed in most of the computers because of their incompatibility with hardware.
This lack of coordination and shifting responsibility for the donated computer equipment frustrated IAPAC’s implementation of I-Med Exchange and highlights the importance, for both donor and recipient, of properly managing donation processes. STF facilitated this substantial donation from Compaq. The equipment was shipped from Compaq’s French division and facilitated by Compaq South Africa (where CDROM drives and internal modems were added to the PC bundle). When technical difficulties arose, it became impossible to identify who could provide assistance and who was accountable.
After almost a year of dealing with this critical difficulty, a technical memo written by Compaq surfaced, which documented that a known incompatibility exists between the model of computer that had been donated and the supplied modems. This finally explained the intermittent instability of the modems and extreme difficulty that many I-Med Exchange participants experienced in maintaining dial-up Internet connections. Confidence in the program by its frustrated participants had waned through these difficulties, despite sincere and thorough attempts to get the hardware to work. Many sites still remain affected by the modem problem as no budget was available to purchase new hardware for all participants.
The intention of placing computers in sites that most need them was not without complications. Public sector institutions are often risky environments in which to host valuable equipment, thus adequate provision needed to be made for security in a number of sites, whilst simultaneously ensuring that the computers remained accessible. In a few instances, delays in putting the necessary requirements in place have left the equipment completely unutilized, while the recipients insist that they are keen to retain their computers to use as soon as these arrangements have been effected. Applications have been made to facility administrators to put in place the necessary safeguards, but the typical response to significant delays is that this process usually "takes some time."
The foregoing points emphasize the importance of careful planning and a facility audit prior to shipping computers to remote areas. Unfortunately, the I-Med Exchange budget did not allow for site visits to all remote sites that had applied for participation and the applicants’ assessment of their own environment had to be relied upon, giving them the benefit of any doubt, as there was clearly an enthusiastic and desperate need for physicians to obtain entry into the program.
In most sites, however, this problem with hosting was not an issue, and having the computers available has brought enormous benefit to these recipients. Included in this number, as well, are those who have experienced ongoing difficulties with connectivity, but still find the computers very useful in their work.
All of these experiences demonstrate how important careful planning and coordination, as well as local technical support, are in implementing IT solutions in low-infrastructure settings.
In almost all cases, this was not the first initiative dealing with IT deployment and in many instances there are existing government- sponsored IT service departments and projects that have been dealing with similar issues. These are often not located in the health services though, or comprise pilot projects or very specific services that are not well known to local health workers or managers. This makes them difficult to partner with from the outset.
The seemingly uncomplicated process of allocating personal computer equipment to public sector physicians, together with the sense of urgency in deploying the equipment and focusing on content of the program, was not the most prudent approach after all. Others could learn from this experience. Many months of careful planning "on the ground" may be necessary before fully understanding and addressing infrastructure requirements. In addition, assessment of how users’ individual needs can be addressed and whether they are suitable candidates to enroll, is important to consider. Less ambitious, more geographically focused deployment of the program could have been more appropriate for the I-Med Exchange pilot, given limitations in resources and time.
Despite significant improvements and visionary plans in building telecommunications infrastructure for southern Africa, huge disparities still exist, and these became evident throughout the implementation of I-Med Exchange. Inadequate technology can be an absolute barrier to accessing information and communication.
Digital telephony in South African urban centers, for example, contrasts starkly with outdated analogue dial-up lines in rural areas (where they are even available). Difficulties in accessibility are further exacerbated by the relatively high costs of telephone services, all of which are charged by the minute.
In addition, telephone lines might not be available where the computers are meant to be used. In Swaziland, for example, many physicians moved computers into their homes in order to be connected through their personal phone lines.
Hosting a computer that requires Internet connectivity within public sector health facilities is also complicated by institutional regulations that tightly control telephone usage. This is done largely to reduce costs; avoid inappropriate usage of scarce communication resources (some hospitals only have a couple of telephone lines that serve the entire facility); and to limit calls to cellular and long-distance locations.
Participants in South Africa were provided with an ISP subscription through a provider that is a subsidiary of the national telephone company (Telkom), in order to allow all dial-ups to be achieved through a "Sharecall" service. Through this scheme, the user only ever pays for the cost of a local call, regardless of the location of the nearest "point-of-presence" of the ISP. Although this is the most sensible option, in some cases the "086" prefix of this number was interpreted by hospital "switchboards" as being a restricted long-distance or cellular service. That raises the further issue of connecting to the Internet via hospital PABX switch-boards in general, which is often problematic. Many of the older PABX systems are not compatible with Internet connectivity, offering slow analogue connections or unstable switching.
Technical consultants advised that I-Med Exchange should supply a satellite connection to all participants in remote sites and replace remaining modems with new external modems. The satellite option would require the installation of additional hardware and software and a monthly connection fee. The estimated total costs of maintaining satellite Internet access with a two-year contract for 86 computers was US$50,000 (including an initial cost per site of approximately US$300 for hardware and additional Internet subscription fees of US$240 per annum for each user).
Although the satellite solution was tested successfully, it was determined that providing satellite connections and replacing modems was too expensive and not within budget. Unfortunately, when technical difficulties were discovered and solutions found, the resources required to remedy these problems were not available.
At the outset of the program, Akamai Technology, a leading provider of streaming audio and video for educational purposes, had agreed to host a series of 15 seminars for I-Med Exchange. Unfortunately, this arrangement proved technically impossible in pilot "test-runs" due to inadequate bandwidth.
Between February 2001 and July 2001, I-Med Exchange was put on hold in an attempt to rectify the logistical and technical problems in the way of delivering Web conferencing. Centra software was added to the program in June 2001. Centra, a leading e-learning platform, was chosen because it was seen as more user friendly and could operate with a lower speed modem connection (28,800 bps) over low-bandwidth (ordinary telephone) dialups. Centra provides "integrated voiceover IP, over dial-up network connections." HIV/AIDS education would be delivered through an online classroom training platform and Web conferences would be offered to participating physicians.
Despite the expectations that Centra would help in resurrecting the program, an early evaluation in Botswana found that participants had problems with the complexity of Centra and the amount of time it took to download the initial file. Where the program works (mostly in South Africa, where adequate connectivity exists to a far greater extent), it is an impressive tool with huge potential. Further work is being done to find ways of improving access to this system and to address remaining obstacles, such as regulatory concerns.
After implementing the highly functional Centra system, regulatory concerns were raised about IAPAC’s use of "voice-over Internet protocol," the technology on which Centra’s real-time communication capacity is based. Under current South African telecommunications legislation, "voiceover Internet protocol" is considered illegal, and this applies to all such communication originating from South Africa (and so impacts on all I-Med Exchange sites).
This legislation has been under review, as part of a larger restructuring of the telecommunications policy framework. In the meantime, IAPAC has attempted to seek further clarity on the issue and has taken a cautious approach to using the technology in I-Med Exchange, in anticipation of possible regulatory changes.
Basic computer literacy skills training was not provided to I-Med Exchange participants, which led to some less IT-experienced participants becoming frustrated. This oversight emphasizes the importance of investing in user training as part of any technology-driven initiative (particularly when introducing new technology).
Implementing an IT intervention in developing countries requires devoted participants, since there is much to be learned by both the providers of this technology and participants. Barriers to utilization must be recognized and appreciated in order to understand and mobilize forces that will motivate and inspire physicians to continue using the system. To retain interest in such a program, there must be some reward or compelling benefit for devoting the time required. This incentive can be that the program offers unique information, or accreditation towards professional development.
I-Med Exchange program physicians agreed that they would participate in this pilot initiative but some deserted the program in frustration or through lack of motivation. Yet, many others strove to overcome the problems by their own resourceful measures. Nick Hone, a physician in Botswana, found the content of the program so useful that he gave up on his regular dial-up connection and connected to the sessions through a satellite service at his local Internet café. This is testament to the dedication of the vast majority of physicians in the region to finding creative solutions to medical education needs and care provision, something deserving of our unrelenting support. Further, Hone’s example is a clear demonstration that there are alternatives for making I-Med Exchange work where conventional infrastructure is lacking. We must continue to research all possible solutions.
Other logistical barriers for users existed, however. Many physicians had difficulty with the timing of the online meetings, since some leave work before the scheduled time. It was difficult to find consensus on one meeting time. Also, some doctors are so busy with their practices that they could not commit the time required to participate in the program. This speaks to the general state of affairs, where physicians participating in ventures such as I-Med Exchange, are doing so at the expense of already limited personal time.
The costs of deploying, supporting, maintaining, and managing the large network of I-Med Exchange computers at remote sites across southern Africa were completely underestimated.
As mentioned, computer hardware received as a donation needed considerable additional expenditure to make it useful, and then over half of the internal modems supplied required replacing due to their incompatibility with the computers and further hardware failure.
Limited technical support was contracted through IT consultants in each country, but became prohibitive as the support requirements escalated mainly due to connectivity problems that required specialized investigations (which identified hardware failure as the primary cause only after some time and considerable expenditure). This also prolonged the program’s implementation phase, which accumulated still further costs. The most beneficial alternative under these circumstances would have been to contract a commercial network of Compaq-preferred technical support providers on a monthly subscription per computer basis, to provide continuous on-site and telephonic support.
Centra Corp. and Dimension Data supplied their online learning and knowledge management applications to be used in this program at a highly reduced fee, but this still added significantly to unanticipated expenditure. An Internet and application server, together with hosting fees, was acquired to run the Centra application, at further cost.
Insufficient human resources were allocated to this program, which should ideally have employed at least the following: an IT technician; a Centra system administrator and support staff; and the project manager, originally budgeted for.
Given unavoidable delays in the implementation process, funding constraints were encountered where certain of the barriers could have been overcome with adequate additional resources. A number of applications were made for sponsorship and funding, specifically to replace faulty equipment and to enhance connectivity through satellite Internet. To date, however, no additional funds have been secured, but the basic program has continued to be subsidized by IAPAC through allocation of general revenue. A sustainability model has been designed that will attempt to generate revenues through expanding the user base and charging subscription fees. This is a scenario that would ideally be avoided, however, since the cost would prove prohibitive to many of the physicians who would want to take advantage of the program.
In the face of the many challenges and frustrations, the continuing dedication, enthusiasm and gratitude of most I-Med Exchange participants has renewed IAPAC’s commitment to searching for ways to refine and improve the program. IAPAC continues, steadfast in this commitment, despite the absence of further donor funding after the pilot phase. Targeted proposals that seek funding for specific components of the service are still being generated and partnerships are being sought that can produce mutual value and strengthen I-Med Exchange’s sustainability.
Numerous secondary benefits have accrued that have also catalyzed new ways of working together as a network of dedicated health professionals in this region. They have led to incremental contributions and new prospects that have strengthened IAPAC’s presence in the region through helping build a Technical Resource Network of Associate Members. These initiatives will continue to grow, supported by the new communication, collaboration, and information-sharing tools, infrastructure and experience that have been established through the program.
I-Med Exchange has been unique in its scale and is a groundbreaking mission to target some of the most under-resourced settings, where the need for this type of information and remote support was perceived to be greatest. Unfortunately, this mission is riddled by the difficulties and complications posed by the very location of these pilot sites—simply because telecommunications infrastructure is still inadequate in many parts of rural southern Africa. Hopefully the bigger, politically supported drive toward building information communications technology capacity in Africa, as a vehicle for sustainable development, will change the landscape of what is possible over coming years.
No equivalent examples of either commercial or developmental initiatives exist, that have attempted to achieve a similar level of IT distribution across the rural expanses of the southern African region. At the same time, I-Med Exchange has also pioneered the deployment of software applications and communication tools that have never been used in this setting before. The program’s achievements in this respect alone have been monumental.
The largest and most frustrating impediment to this program’s success, created by a large and reputable company’s oversight in donating computer equipment that did not function properly cannot and must not be neglected. This serves as an important reminder of what most commercial hardware suppliers already know— that IT is so much more than equipment. Technical service to back up hardware is an absolutely essential part of the equation necessary to make IT useful (in any setting).
The experience and insights gained through the pilot phase of I-Med Exchange have been substantial, since this program has challenged the boundaries of what is technically possible within low-resource infrastructure. Project staff, program participants, and IAPAC as the implementer, have demonstrated a high level of tenacity, perseverance, and innovation in the face of significant difficulties; something which provides more than a ray of hope that the initiation of this program will ultimately prove a major watershed event in combating the global pandemic.
Based on what has been learned, and the array of diverse opportunities that have emerged as a result of this program, IAPAC is ready to move forward with I-Med Exchange, at this point in a somewhat different format.
First, donated hardware is being recalled from certain sites and re-deployed to targeted key sites that have the necessary infrastructure and technical support in place. These limited sites, with their added hardware, will be used to initiate satellite Tele-Centers (linked to and supported by IAPAC’s Regional Information and Training Resource Centre, that will serve as the "hub" of these peripheral sites).
"I-Med Plus" has been created to take advantage of the powerful applications in online learning and knowledge management provided by Centra. This will add to the basic services offered through I-Med Exchange by including access to HIV related journals and other information resources.
Online training and collaboration sessions will be extended to include online case presentations and journal clubs. Key conferences (starting with IAPAC’s 5th International Conference on Healthcare Resource Allocation for HIV/AIDS, which took place during April 2002) will be broadcast as "streaming" Web conferences.
Subscribers will also now be able to take advantage of a scheduling system in order to hold their own "online meetings" with groups of colleagues located anywhere in the world. This may be used for purposes of collaborating on research, to hold clinical or policy consultations, or for any other small or large group discussion/training session that may assist their work.
A "knowledge portal" is also being established as the "virtual" hub of IAPAC’s Regional Informal and Training Resource Centre. This hub will provide access to growing archives of information and training "knowledge objects" that can be incorporated into individualized accredited learning programs, using the powerful functionality of "Centra Knowledge Center." I-Med Plus is being made available on a subscription basis to any individuals or institutions that have their own computers and Internet connections. I-Med Plus will also be used to support and facilitate collaboration among IAPAC’s Technical Resource Networks of Training, Research, and Clinical Associates.
Much has been invested into I-Med Exchange as a pilot program that sought to demonstrate what role IT could have in supporting HIV/AIDS care within less developed settings. This comes not only by way of money, but also of time, energy and spirit. The program has evolved, by means of the implementation phase, from a visionary and pioneering idea into a realistic set of services and tools. These services and tools will continue to be enhanced, and can also serve to support other training, collaboration, and information management initiatives. In the process of this program growth and refinement, the I-Med Exchange experience has assisted in revealing other important opportunities, and has helped to build networks and regional focus among physicians.
The value of these lessons and secondary benefits cannot be underestimated and are the primary basis on which to define I-Med Exchange as having been a worthwhile initiative. As IAPAC, its partners, and those participating in I-Med Exchange look to the future, we are confident that the momentum and successes achieved to this point will ultimately prove but the root of a vast, flourishing tree of health and wisdom.
Access to technology in 2000 – see table 2.
Patrick Connelly is the Director of Research and Development for the IAPAC Southern Africa Regional Office (SARO).
020510
IA020502
Copyright © 2002 - International Association of Physician's in AIDS Care (IAPAC). Reproduction of this article (other than one copy for personal reference) must be cleared through the IAPAC.
AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, iMetrikus, Inc., John M. Lloyd Foundation, the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2002. This material is designed to support, not replace, the relationship that exists between you and your doctor.
AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1980, 2002. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .
