Ehealth

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ICT in Health (R.J.Rodrigues), Version 2
Information and Communication Technologies in Health Practice

Adoption and Challenges in Latin America and the Caribbean
Roberto J. Rodrigues1
Information systems, communications, and collaborative work are critically important to the delivery,
accessibility, and quality of healthcare; for the logistical management of health systems; and for the proficient
operation of health organizations. Since the early 60’s, incorporation of computer systems into the operation of
healthcare services of developed countries led to the progressive automation of libraries; business offices; the
management of physical assets, stocks, and patient administrative data; instrumentation and diagnostic
equipment; and the implementation of departmental systems, initially in the clinical laboratory and later in many
clinical care areas and health organizations.
Information and communication technologies (ICT) are the enabling components that support processes carried
out by health institutions, care providers, and health programs. The imperative for ICT in the health sector is
concrete and essentially driven by the operational requirements of healthcare services and organizations -- of
which there are many in terms of national models, institutional formats, and governance -- all functioning in
shifting social, economic, and political environments. In the last two decades the health sector has shown:
• Growth of complex and segmented health service markets
• Ubiquity of interactive communications and networks of producers, suppliers, customers, and clients
• Expectations about solutions for telehealth services, second opinion, communities of practice, evidence-
based decision support, consumer-oriented information, and health promotion
• Growing importance and need for professional continuing education
• Efficiency in service management, strategic alliance models replacing traditional business organizations
based on ownership of physical assets and long-term structures
• Need for rapid responses and forecasting demand
• Demand for customization capable of achieving a “one of a kind” product or service and customer
satisfaction
In the past 15 years, advances in ICT and the dissemination of networked data processing and interactive
applications created an environment of universal access to information resources and technologies along with
the globalization of communications, businesses, and services with both optimistic and alarming implications for
the future of health practice. Promising health ICT applications are oriented to professional networking,
integration of the clinical care process management, standardization of patient records and provider
communications; and the delivery of network-based health information and services, including remote
monitoring and direct care. This expanded view of health ICT has been promoted by the ICT industry,
professionals, and development agencies as the final stage in bringing online the entire healthcare system.
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eHealthStrategies, Bethesda MD, USA and Information and Knowledge Management Area (DD/IKM), Pan American
Health Organization/Pan American Sanitary Bureau, Regional Office of the World Health Organization, Washington DC,
USA
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1. Medical, Social, Economic, and Organizational Issues in the Health Sector
In developed as well in developing societies, and in any health sector organizational model, four core
performance and outcome challenges are present: increase coverage; provide an ever-expanding range of
health services; ensure equitable access to quality services; and reduce or, at least, control costs.
1.1. Healthcare Services in Latin America and the Caribbean
The following critical issues have been identified for the health sector of Latin America and the Caribbean, [1]:
• Changing demographics, particularly age structures and the “graying” of the population in mid-income
countries, lifestyle, urbanization, and growing industrialization. Aging population groups require greater
subsidized medical care and a growing demand for high-cost diagnostic and therapeutic resources.
• Large number of individuals without access to basic healthcare and health information, many living in
marginal urban areas with multi-sector shortcomings (housing, sanitation, education) and a healthcare
system with chronic deficiencies in terms of infrastructure, distribution, personnel, and services.
• Shifting epidemiological profiles putting an increasing burden on healthcare services and on the society. In
high- and middle-income countries, about 40% of the population has been shown to suffer from one or
more chronic conditions and in some, chronic conditions account for up to two-thirds of costs.
• The “know-do gap” -- scientific knowledge and significant opportunities do exist to improve health status but
still there is a considerable prevalence of preventable diseases and premature deaths, both in absolute and
relative terms due to inadequate access to evidence-based knowledge.
• Despite the fact that the health sector is essential to the welfare of the population, to the formation of
human capital, and for economic advancement, it has not kept up the pace with the momentum of change
experienced in recent years by other productive segments of society.
• Uneven access to basic and specialized health services results in many regions, communities, and social
groups being left without access to even the most basic care or, when it exists, there is poor linkage to
second and tertiary levels for consultation and management of problems identified at the primary level.
• Disconnected actions in the provision of care, overlapping of responsibilities, and wasteful use of resources
leading to quantitative and qualitative deficiencies in the delivery of services.
• In most countries the health sector is underfinanced, there is inefficient or wasteful allocation of scarce
resources, and lack of coordination between health subsectors, institutions, academic and research
centers, and other social agents and stakeholders.
• Health sector expenditures comprise 6.0% to 17% of the service sector that, in turn, accounts for 50% to
65% of the GDP in almost all countries. The market for health goods and services in the countries of the
region represent 9.0% of the global health market, more than Eastern Europe and Central Asia combined
and just below that of East Asia and the Pacific. The 1999 average per capita expenditure in health in Latin
America and the Caribbean in PPP dollars was US$ 452. Compare this value with US$ 1,868 for the
European Union, US$ 2,206 for Canada and US$ 3,978 for the United States [2]. There is a marked
variation on the national expenditures among countries, even for countries of comparable income level
although healthcare expenditures typically are concentrated to a limited set of health conditions— the
“80/20 Rule”.
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• Rising costs are mostly driven by technological innovation such as drugs, diagnostic and therapeutic
modalities, instrumentation, and digital devices. Although innovation and technological changes in medicine
are not new phenomena and picking up speed since the 16th century, what is new, however, is the number
of innovations and the momentum by which they are disseminated and incorporated into medical practice
and ICT are fast becoming a significant cost component in healthcare organizations.
• Who sets priorities for the deployment and access to technological innovation and who are those that
benefit from scientific and technological developments are major issues of social, political, and economic
significance and carry a heavy weight in national politics.
1.2. Reforming the Health Sector
In many countries, including significant segments of the population of industrialized societies, individuals still do
not have access to appropriate care or cannot afford it. Traditional revenue streams that have supported
indigent care, public health interventions, medical research, and education are insufficient or are being reduced,
prompting the search for new methods to support those essential activities. Health sector reform is a process
aimed at introducing substantive changes into the health sector and in the relationships among stakeholders
and their roles, with a view to increase equity in benefits, efficiency in management, and effectiveness in
satisfying the health needs and expectations of the population. [3, 4, 5, 6]. In market economies, competition,
merger of provider organizations, aggressive contracting by payers, and increasing involvement of employer
and government purchasers have characterized health system reform processes [7, 8, 9].
Health reform in Latin America and the Caribbean countries has commonalities but different facets, no single
model being adopted by all. Each country is moving at a different pace in the implementation of its own
particular health system model but the economic and globalization changes of the last years have brought a
new urgency to reform processes. Common trend-setters and responses that characterize the objectives of
most health sector reform processes occurring in the Region are: [3, 8]:
• The universalization of a high cost-benefit basic package of health services with a set of standardized
public health interventions;
• Cost containment and recovery;
• Administrative decentralization and operation of healthcare services;
• Recognition of the role of the private subsector and the intersectorality of health interventions;
• Health models oriented towards primary care and centered on people;
• Focus on quality and accountability; and
• Moving away from the reactive delivery of care to a more proactive management approach of the health
status of individuals and population groups.
2. Information and Communication Technologies in the Health Sector
In the health sector, ICT is diffusing at a rate consistent with other similar service sectors that require complex,
highly networked products. From an outcome, performance, and efficiency driven perspective, information and
communication technologies have been important enablers of change, particularly in the conduction of routine
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activities -- this being especially true for complex processes -- addressing three implementation environments
[10, 11, 12, 13, 14, 15, 16, 17, 18]:
• Managerial and Educational -- logistics of care provision, health system planning and operation, resource
administration, management of biomedical technical and scientific knowledge, and the development of
health personnel
• Clinical Care and Public Health -- creation, maintenance, and sharing of personal, community, and
population health data by providing remote user access to patient administrative functions such as master
registration, scheduling, and the recovery of longitudinal medical record information in chronological,
problem, and source-oriented formats including provider contacts, reports, transcribed notes, current
medications, diagnostic data, demographics, etc.
• Specialized Health Applications -- support to technical interventions and diagnostic and therapeutic
functions such as medical imaging and physiological data acquisition and analysis. Advanced systems
provide guideline-based content and patient- and condition-specific reminders, automated diagnosis,
population data analytical and management resources, interprovider communication facilities, and auditing
tracks.
Health ICT applications have characteristics regularly found in other information- and knowledge-based
industries and most ICT solutions applied to the health sector are identical to those used in other social and
productive sectors or otherwise share common elements. They (a) provide operational support of technical
functions, (b) support knowledge management, (c) are frequently implemented in complex environments, (d)
require specialized human and organizational resources, (e) use computer-based technologies and
telecommunications, and (f) are dependent on aspects related to fast-changing innovation and market demands
and expectations.
2.1. ICT in the Context of Healthcare Technologies
The U.S. Congressional Office of Technology Assessment (OTA) defined medical technology as “the drugs,
devices, and medical and surgical procedures used in medical care, and the organizational and supportive
systems within which such care is provided” [19]. Later on, the term health technology was introduced to
broaden that scope also to include disease prevention and health promotion technologies. Health technology is
categorized into three classes:
• Diagnostic Technology - such as electrocardiography, electroencephalography, myography, x-ray imaging,

fiberoptic endoscopy, computerized tomography, magnetic resonance imaging, ultrasonography, coronary
angiography, non-invasive functional organ studies, radionuclide uptake and imaging diagnostic
procedures, biochemical, hematological, serological, microbiological, and tissue pathology analytical
studies, genetic analysis, etc.
• Therapeutic Technology - including curative and preventive technologies such as pharmaceuticals,

laparoscopic and laser surgery techniques, vaccination, radiation by external sources or radionuclides, and
the evolving applications of genetic engineering and gene therapy to human disease,
• Information Technology - including manual and computerized data systems, medical records, clinical and
administrative documentation, communication resources, fax machines, telephone, e-mail, the internet,
handheld computers and portable digital assistants (PDAs), electronic medical records, and “smart cards”.
Diagnostic, therapeutic, and information technologies are most useful when they coexist at a similar level of
development and when linked -- a health program that uses advanced diagnostic resources and fails to provide
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the resources needed for an effective therapeutic solution will not improve the health of a target population. The
same can be said about ICT solutions promoted and implemented in a healthcare environment that lacks
appropriate organizational, physical, and human infrastructure.
2.2. Evolution of ICT Applications in Health Practice
As a general rule ICT applications in the health sector evolve by the upgrading of old applications and by the
introduction of new solutions and applications to support areas hitherto not provided for and, more rarely, by a
total abolition or substitution of an entire area of application.
Initially, the predominant ways by which ICT were introduced and applied within the healthcare system related
mainly to the operation of administrative, managerial and financial functions. Over the past forty years,
applications have evolved by providing a great variety of data-processing resources aiming the improvement of
health services management and patient care through the support of clinical and administrative messaging; the
operation and administration of resources; logistical management of health sector functions; patient information;
health education and promotion; epidemiological surveillance and health status monitoring; clinical decision
assistance; knowledge management; image and signal analysis; modeling; and remote consultation and
intervention (Figure 1) [18, 20, 21, 22, 23, 24, 25].
00’s
90’s OR G A NIZ AT IO N AL
R EEST R UC T UR ING
(HE A LT H R EF OR M )
80’s C O NT INUIT Y
OF C AR E
70’s C LINIC A L • K N OW LE D GE
SER VICE M AN AGE M E NT
R EEST RUC T UR ING • E V ID E NC E -B AS E D
60’s C LINIC A L P RAC TICE
SER VICE • P ATIE N T F OC U S
• INTE R S E C TOR AL
M AN AG EM ENT • P LANN IN G • INTE R OR G AN IZATION LIN K AGE S
PAT IE NT LINK A GE S
• P R OD UC TION LIN E
M AN AG EM ENT P ROC E S S
M AN AGE M E N T
• C LINIC AL C OS TIN G • RE S OU RC E • DIS TR IBU TE D

M AN AGE M E NT P ROCE S S IN G
• C LINIC AL P R OC E S S • LON GITUD IN A L
• C LIN IC AL C AR E M AN AGE M E N T P ATIE N T R E CORD • D AT A W AR E H OU S E
• FAC ILITY • COM M U NITY H IS • INTE RN E T
M AN AGE M E N T • IN TE GR ATE D AP P S
• RE LATION ALDB • TE LE M E D IC INE
• ADM IN IS TR ATIV E
P R OC E S S C ON TROL • LOGIS TIC AL • EMR
• ADV AN CE D C LINIC AL S U P P OR T S W
DAT A P R OCE S S ING • DE C IS ION S UP P ORT
• S IM P LE CLIN ICAL • OP E R ATION S • RE S OUR C E

D AT A P R OC E S S IN G R E S E AR C H M AN AGE M E NT AP P S
• TR AN S ACTION AL • C OS T AC C OU N TIN G
AD M INIS TR ATIV E AP P S
AP P LIC ATION S HE A LT HC AR E PAR A D IG M
O PER AT IO N A L DET ERM IN A NT S
IN F OR M AT IO N T EC H N OL OG Y
Figure 1. Over the Past Four Decades Health Applications of Information

Technology Evolved in Response to Changing Operational Determinants [26]
From the early administrative and patient management implementations to the organizational restructuring and
collaborative work model paradigm of our days, ICT has been deployed in the health sector to provide specific
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solutions to the operational determinants of each health system design model. A characteristic of health sector
ICT is that the introduction of a new organizational paradigm does not completely bring previous models to an
end but, nearly always, just adds a new dimension to them. This evolutionary perspective is clearly seen in the
deployment and functioning of information systems; transactional administrative systems, logistics, resource
management, administrative process control, and patient clinical information applications of past and recent
technological generations continue to coexist in support of health system operations – and the issue of legacy
systems being a lingering problem for early adopters [9, 19, 26, 27, 28, 29, 30, 31, 32, 33]. Particularly since the
advent of the Internet public networks a host of opportunities for the health sector have emerged including
access to knowledge for personal health decisions and behaviors, new modalities of health care delivery, and
operational support to public health and to community-oriented systems. Of special note is the fact that
telecommunications made possible widespread access to the largest volume of health knowledge in history --
people now can seek support and advice from potentially millions of online peers and professionals worldwide at
any time.
From the service delivery perspective, there is a growing regionalization of specialty-based medical
technologies that consider population distribution, epidemiological profiles, and economies of scale. The global
demand for telehealth services is estimated to be of US$1,25 trillion, of which about two-thirds is for direct
services and the rest for second opinion, consumer information, continuing education, management and other
services [18, 21, 27, 34, 35, 36, 37, 38, 39].
2.3. ICT and Health Sector Management and Operation
The variety of environments, priorities, organization, and operational demands of the healthcare sector require a
great diversity of resources and solutions capable of providing support for the challenging and complex
interdependent clinical, public health, and managerial decisions and interventions that characterize the ever-
changing health practice [20, 27, 38, 40, 41]. The health reform processes implemented or being under study in
most countries can take advantage of the experience with ICT solutions build for other social, service, and
productive sectors of society that share similar determinants of change [42, 43, 44]. Advanced ICT resources
have been recognized as appropriate for operational support of a new health and healthcare models [8, 21, 27]
focused on individual information, data mining, and concomitant access by multiple users. They also address
the new trends in healthcare emphasizing continuous relationship between providers and clients; customization
of care; expanding partnering of providers, insurers, and clients; increasing client control of evidence based-
health decisions; information that is not frozen in paper records kept in separate sites with access limited to their
creators but available electronically to all stakeholders; and transparency and cooperation among healthcare
providers instead of independent professional roles.
Competition, merger of provider organizations, aggressive contracting by payers, and rising involvement of
employer and public purchasers have characterized the changing processes occurring in health services
management. Those models of care require, beside innovative functions, different responsibilities for users and
providers. New roles are expected for providers and the involvement of new professionals, including from non-
health sector areas, and the local government together with the increased role for local governance (e.g.
municipalities and individual health provider organizations) and non-traditional professional categories.
2.4. Matching ICT Applications to Health Sector Requirements
Even in developed countries, most public and private healthcare ICT applications evolved in a patchy and
inefficient way with limited number of standardized data-related definitions and processes in place, a
prerequisite for efficient systems deployment. Besides those shared specifications, information systems must be
appropriately designed and implemented in order to support the great diversity of perspectives and operational
requirements of regulators, managers, payers, providers, and clients [21, 27]. In order to reap the full benefits of
such innovative data processing, communication, and use, it is necessary to have a clear definition of goals;
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effective collaboration among stakeholders; appropriate technology infrastructure, systems integration, and
standards; and the implementation of performance metrics. Current developments in the health systems of
developed countries that can be successfully supported by ICT are characterized by [7]:
• Economies of speed associated to economies of scale
• Custom-built products and services (“individualization of care”)
• Convenience and “real time” processes (“customer satisfaction”)
• Dealing with the short life cycle and rapid obsolescence of explicit evidence-based knowledge
• Capturing and sharing the tacit knowledge of health professionals
• Modularity and standardization of basic components (“reuse”)
• Convenience and safety becoming more important than price (e.g. kits, one-time use devices)
• Emphasis on more effective use of existing technologies than on the introduction of new solutions
• Evidence-based justification for deployment and utilization of new technologies
• Safety, confidentiality (“data protection”), and regulatory concerns
2.5. From Health ICT to e-Health
Rarely mentioned before 1999, the eHealth concept evolved from fields previously known as telehealth and
telemedicine to now serve as a general designation to characterize not only networked health applications, but
also virtually everything related to computers and medicine overlapping traditional medical informatics and
public health combining electronic communications and information technology to transmit, store and retrieve
digital data for clinical, educational, and administrative purposes, both at the local site and at distance [45, 46,
47]. The term eHealth was first used by industry leaders and marketing professionals rather than academics.
Intel referred to eHealth as "a concerted effort undertaken by leaders in health care and hi-tech industries to fully
harness the benefits available through convergence of the Internet and health care." Because the Internet
created new opportunities and challenges to the traditional health care information technology industry, the use
of a new term to address these issues seemed appropriate. The "new" identified challenges were: (a) the
capability of consumers to interact with their systems online (B2C = "business to consumer"); (b) improved
possibilities for institution-to-institution transmissions of data (B2B = "business to business"); and (c) new
possibilities for peer-to-peer communication among consumers and providers (P2P = "peer to peer") [40, 41,
48]. eHealth development followed a pattern started by other "e-words", such as e-Commerce, e-Business, e-
Finance, e-Learning, e-Government, e-Solutions, and e-Strategies.
An author [48] defined ten areas were the implementation of eHealth solutions should promote significant
changes:
• Efficiency - one of the promises of eHealth is to increase efficiency in healthcare, thereby decreasing costs.
One possible way of decreasing costs would be by avoiding duplicative or unnecessary diagnostic or
therapeutic interventions, through enhanced communication possibilities between health care
establishments, and through patient involvement.
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• Enhancing quality of care - increased effectiveness and improved quality. eHealth may enhance the quality
of healthcare by allowing comparisons between different providers, involving consumers as additional
power for quality assurance, reducing errors, and directing patient streams to the best quality providers.
• Evidence based reasoning - eHealth facilitates evidence-based decision making in a sense that their
effectiveness and efficiency should not be assumed but proven by rigorous scientific evaluation.
• Empowerment of consumers and patients - by making the knowledge bases of medicine and personal
electronic records accessible to consumers over the Internet, opening new avenues for patient-centered
medicine, and enabling evidence-based patient choice.
• Encouragement of new relationships - between the patient and health professional, towards a true
partnership, where decisions are made in a shared manner.
• Education of health professionals and citizens - through online sources (continuing medical education) and
consumers (health education, tailored preventive information for consumers).
• Enabling standardized information exchange and communication - between healthcare facilities, levels of
care, and caregivers.
• Extending the scope of healthcare - both a geographical sense as well as in a conceptual sense. eHealth
enables consumers to easily obtain health services online from global providers. These services can range
from simple advice to more complex interventions or access to products such as pharmaceuticals.
• Ethics - eHealth involves new forms of patient-physician interaction and poses new challenges and threats
to ethical issues such as online professional practice, informed consent, privacy and equity issues.
• Equity – aiming at making healthcare more equitable.
Most eHealth solutions build on strategies and experiences in using Internet-based networked technologies to
rethink, redesign, and rework how businesses and public services operate. Typically, such developments have
been aimed at the improvement of productivity, effectiveness, and efficiency, both internally and in the
relationships with clients, customers, suppliers, and partners. The essence of eHealth, as in e-Commerce, is
reliable transaction delivery in a fast-changing environment involving people, processes, and a business
infrastructure focused on the ill or healthy citizen.
Many eCommerce solutions share common elements with the health sector allowing healthcare organizations to
migrate to a customer-focused environment and make the transition to a collaborative patient care management
strategy. In developed countries, eHealth has rapidly evolved from the delivery of online medical content toward
the adaptation of generic solutions to the processing of health-related administrative transactions and logistical
support of clinical tasks. Besides the intensive use of advanced information and communication technologies,
such applications are grounded on explicit process standardization and economies of scale and oriented to
networking, integration of the clinical care process management, and the provision of Web-based health
information and patient care, including remote monitoring and healthcare [20, 22, 30, 49, 50, 51, 52, 53].
Frequently, eHealth is equated to telemedicine; however the latter term should be more appropriately applied to
the use of ICT for remote clinical consultation, case review, and second opinion. In a broader sense, eHealth
characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a
commitment for networked global thinking, to improve health care locally, regionally, and worldwide by using
information and communication technology [48, 54].
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eHealth applications have been deployed in the following areas [7]:
• Professional Communication among Providers

• Logistics of Patient Management and Distributed Provision of Care
• Health System Administrative Transactions
• Business to Business Transactions
• Business to Consumer Transactions
• Biomedical Knowledge Management
• Electronic Health Record (Computerized Patient Record)
• Clinical Care (Telemedicine)
• Health Information Delivery to the Public
• Distant Education of Health Professionals
• Consumer to Consumer Exchanges (Chat and Special-Interest Groups)
2.6. Market for ICT Products and Services
In many developing countries the market for ICT products and services is limited. The hospital subsector is
characterized by small facilities – e.g., in Latin America and Caribbean 60.5 percent of the hospital facilities
have 50 or fewer beds (Table 1) – that cannot afford major capital expenses in deploying ICT resources and
would be hard-pressed to meet the operational costs to maintain in-house applications.
Number Hospitals Beds

Beds
n % n %
1-50 10,027 60.5 219,383 20.0

51-100 2,615 15.8 189,559 17.3
101-200 1,703 10.3 242,770 22.1
201-300 544 3.3 133,225 12.1
301-400 242 1.5 84,811 7.7
401-500 133 0.8 58,951 5.4
501-1000 186 1.1 126,169 11.5
>1000 29 0.2 43,097 3.9
Sub-Total 15,479 93.4 1,097,965 100

No Data 1,087 6.5
Total 16,566 100.0
Table1. Hospitals in Latin America and the Caribbean by Number of Beds

(PAHO HSP/HSO Directory of Latin America and Caribbean Hospitals, 1996-1997)
Resources, products, and markets that are highly specialized, closed, and regulated are being swiftly opened to
new players in a marketplace that is mostly unregulated and, at the same time, when novel and untried health
reform models and ICT are being introduced. These circumstances carry with them a high unpredictability of
outcomes. The straightforward transference of the e-Commerce experience and solutions to the health sector is
not straightforward since the healthcare environment has characteristics that are quite different from an “ideal”
competitive market guided by rational decisions and the balance of availability and demand for goods and
services. Such differences include: (a) social goals of the health sector (equity of access and quality of care); (b)
restricted number of producers (healthcare providers); (c) self-interest is the main guiding force for providers
and consumers (patients); (d) provider makes most of the “buying” decisions (information asymmetry); (e) many
barriers to entry; (f) monopoly supported by regulatory and legal instruments; (g) branding is generalized
(providers, pharmaceuticals); (h) multiple uncontrolled externalities; and (i) high risk and uncertainty or
irreversibility of outcomes. Moreover, in the health sector there is low price elasticity for goods and services.
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Unfounded vendor-driven expectations of how the Internet will revolutionize healthcare have too often overshot
their target. Overestimation of results and consequent unfounded expectations is a frequent pitfall. A common
error has been to regard technology as the solution for logistical, administrative, and knowledge management
problems of healthcare. The lesson to be learned for eHealth is that technology is a tool, which can be justified
economically only if organizations deploy it in a real practice environment and closely track how managers and
direct care professionals are using it. This requires the stepwise development and implementation of processes
and metrics to monitor productivity and impact.
2.7. Presence of an Enabling Organizational and Governance Environment
Understanding a country health sector and ICT infrastructure, needs, expectations, and priorities of countries
must be followed by the development and implementation of national policies and a regulatory framework for
ICT. Policy development is often a long evolutionary process [23, 24, 35, 53, 56, 57, 58, 59, 60]. Those
organizational and governance enablers are aimed at the reduction of infrastructure externalities, coordinate the
implementation of standards, and facilitation and guidance of organization changes required in the deployment
of ICT solutions. The most important decisions relate to finding ways to deal with:
• Policy-related Issues – Inadequacy of policies and norms regarding information technology and, particularly
in the case of the public sector, the lack of national strategies for the standardization and cost-effective use
of technology and information and failure to integrate the different visions of ICT applications as they relate
to health system models. Haphazard development of “islands” of innovation is typically associated with
centers of excellence isolated from national, regional, and local approaches. Inconsistency and stability of
political support, reflected in funding discontinuity, is a major problem in the Region.
• Standardization Issues - Main problems in this area are data-related involving institutional and
organizational standard-setting and their consistent use. Low definition level of contents (deliverables) of
health interventions, indetermination of objectives and functionalities desired for applications, and conflicts
in defining minimum data sets for operational management and clinical decision-making.
• Organizational Issues - Centered mainly on problems related to the inevitable changes of work patterns and
procedures, increased documentation workload for staff and direct healthcare professionals, and issues of
retraining, physical data security, and confidentiality of patient-related data. Resistance to change is related
to professional hierarchy and clearly demarcated roles -- this major obstacle results in unwillingness of
professionals to collaborate in recording and exchanging patient data and there is a general distrust for off-
site data storage and access control. Other organizational and managerial aspects involve limited
information about impending technologies and low health provider capacity to acquire and deploy ICT and
limitations on operating and capital financial resources, market closure, and high tariffs results in low
investment in innovation and technology.
Developing countries may require direct assistance in the definition of ICT policies and strategies as part of their
comprehensive development strategies as well as with the establishment of the appropriate regulatory
environment for competition so that national and foreign private investment can play a role in bringing necessary
seed financing through public-private partnerships.
3. Technological Innovation and Acceptance in the Health Sector
Science and technology are cultural artifacts and exist in a social environment with defined values. Historical
evidence suggests that the prime explanation for the success of advanced industrialized countries lies in their
record of innovation and its application involving different dimensions: institutions, technology, trade,
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organization, and application and control of natural resources. In particular, the characteristics of innovation
itself -- uncertainty, search, exploration, financial risk, experiment, and discovery -- have so permeated the
expansion of trade and the development of natural resources in Western Societies as to make it virtually an
additional factor of production [61].
Technology-driven innovation is a multiple-step interactive process requiring attention to constantly changing

resources and skills involving a wide range of actors and interests, operating under different intents, incentives,
and timelines. Innovative processes, exhibit dead-ends, feedback loops, multi-directional interactions, parallel
developmental paths, and unintended consequences. Besides issues of technology effectiveness and
appropriateness, questions were raised about the social impact of technological innovation and the many ethical
and economic issues related to scientific inquiry and the adoption of innovations. Far-reaching social, cultural,
and political impacts result from the introduction of technological innovations in the health sector -- probably the
most serious is the focus of medical attention on technology without proper assessment of its effectiveness and
its role and impact in the relationship between patient, communities, and the physician.
3.1. Moving Beyond the Health Professional: New Actors and Issues
Traditionally, technology developers considered the physician, acting as agents for their patients, as the
principal user. In recent years, however, other groups -- hospital administrators, patients, payers, and regulators
-- have begun to influence technology-related decisions. Public opinion and perceived benefits, even when
unconfirmed, also play an important role in technology diffusion. Unwarranted enthusiasm may result in the
sometimes premature diffusion of technologies such as was the case with total-body computed tomography
scanning, placing the public at risk of overtesting and overtreatment [62]. Those concerns have been
exacerbated by the steady introduction of new technologies and the increasing gap in access to healthcare
resources among social groups and countries resulting in [49, 63, 64]:
• Class disparities - technology may create economic disparities both between and within the developed and
developing worlds. Those not willing or able to retrain and adapt to new technological opportunities may fall
further behind. Moreover, given the market weakness in developing countries, economic incentives often
will be insufficient to drive the acquisition of new technology artifacts or skills to serve poorer social groups.
• Reduced privacy - various threats to individual privacy and data security have been created by new
technologies. They include diagnostic results databases, increased sensing capability for biochemical
markers, DNA testing, and genetic profiles. There is, however, ambivalence about privacy because of the
potential benefits derived from availability of population-based information. Unfortunately, since regulation
and legislation often lags behind the pace of technology innovation, privacy is generally addressed in
reactive rather than proactive fashion and occasions for major breaks in personal data protection are
constantly being created.
• Cultural threats - many feel that their national or group culture vitality and possibly even long term existence
may be threatened by technology. As the benefits of technology are evident it may be difficult to prevent
such changes and technological innovation has been a major driver for the diffusion of a uniform global
identity across all social sectors, especially among the young.
3.2. The Anti-technology Prejudice
Irrational reaction against science and technological innovation has many causes. In the health sector,
opposition to technological advancement and to ICT in particular, is not rare and is generally cloaked in a
humanistic, alternative, or political discourse, some critics going to the extreme of questioning the very role of
medicine in improving the health of populations [65, 66]. Aligned with more recent postmodern deconstructivism
and the emergence of the misdirected logic at the heart of apparently well-meaning but largely flawed
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arguments of “science studies” academics, this view has argued that modern science only reflects dominant
social interests and cultural values of Western society. Following this line of thought, postmodern scholars have
urged societies to develop their own "alternative science" as a step toward "mental decolonization”. By eroding
all distinctions between science and subjectivism, they have unwittingly aided the spread of fallacies and the
undermining of evidence-based knowledge [67, 68, 69]. This is reflected in the proliferation of alternative cures
and unwarranted claims in the electronic public space of the Web.
Notwithstanding those negative positioning, skepticism regarding established intellectual values and uncritical
enthusiasm for technology had a positive effect in nurturing the evidence-based movement in health, epitomized
by the work of Cochrane, Donabedian, and others and characterized by: concern with broader health issues
including prevention and promotion; respect to appropriateness; public involvement in policy making; concern
with patient’s satisfaction; commitment to quality assurance; and emphasis on accountability [70, 71, 72]. In fact,
the evidence-based movement resulted in profound changes in the diffusion, professional acceptance, and in
the methodologies used to assess technologies and medical interventions.
3.3. Development and Adoption of Innovation by the Health Sector
A high percentage of new medical technologies have emerged not out of biomedical research, but through
transfer of technologies that were developed for other sectors, examples being lasers, ultrasound, magnetic
resonance spectroscopy, and that most general-purpose of all technologies, the computer. Indeed, a drawback
of a linear model of innovation is that it implies that one can make a neat distinction between research and
development (R&D) on the one hand and technology application on the other, without considering the
uncertainty inherent to the former. Furthermore, once developed medical technologies often interact with other
technologies in unexpected ways resulting in unintended consequences and those interactions frequently
cannot be anticipated for the simple reason that complementary technologies may not yet have been invented.
These facts underline two critical characteristics of innovation in medicine: new technologies retain a high
degree of uncertainty long after their initial adoption and a close interaction between developers, often in
industrial laboratories, and users is crucial to the development of new medical technologies. Use of any
innovative technology in a clinical setting likewise requires a complete reorganization of how medicine is taught
and practiced. This adoption inertia is observed even with technologies where scientific evidence is well
established; as an example, George Papanicolau first demonstrated the effectiveness of the Pap smear in the
1920s, but it was not until the 1940s that it was accepted into practice. Health professionals, and particularly
physicians, are generally wary of introducing devices that might interfere with their communication with patients
and the latter, on the other hand, are suspicious of information technologies that might facilitate the
dissemination of personal information to other parties. Because the introduction of a technology may require
major changes in professional practice new technologies require considerable effort, expertise, and commitment
– not necessarily linked to their inherent complexity; for example, the introduction of electronic fetal monitoring in
the 60’s and 70’s required extensive retrofitting of nursing procedures and guidelines to reconcile machine
monitoring with midwifery practice as conducted at that time [73].
Other consequences of technological adoption are the required change in medical education and the
appearance of the specialist. The dramatic increase in specialists and decline in generalists in the years
following World War II was largely due to an explosion of new technology, which required considerable time and
study to master and frequent practice to maintain appropriate skills. In the U.S., in 1940 seventy-five percent of
direct patient care physicians were general practitioners -- by 1949 that number had dropped to sixty-five
percent and in 1975 family physicians accounted for only 13.8% of the physician population [74].
Motivation for providers and hospitals to adopt a new technology is an issue of considerable policy relevance. A
study of the adoption of magnetic resonance imaging in the U.S. showed that there are multiple determinants for
embracing a new technology: provision of better services, technical and professional preeminence, clinical
13
excellence, attraction of new specialists, image building, and revenue generation. Furthermore, insurance and
reimbursement insulates providers and patients from the immediate financial consequences of the use of new
and expensive technologies [75].
Studies have shown health professionals increasingly using and accepting the Internet paradigm for information
and knowledge sharing. Evidence of this phenomenon is the growth of interactive health communication by
which individual consumers, patients, caregivers, and professionals access or transmit health information, or to
receive or provide guidance and support on a health-related issue through electronic communication
technologies to relay knowledge, enable informed decision making, promote healthy behaviors, promote
information exchange and promote self-care, or manage demand for health services [76, 77]. A global survey
demonstrated that 80% of physicians across eleven North American, European, and Asian countries own a
computer and 44% of these physicians have accessed the Internet. The predominant place of Internet access is
in the home. Among physicians who have not yet accessed the Internet (56% of physicians in the eleven
countries surveyed), two-thirds intend to do so soon. The overall result is that more than 80% of physicians
(90% in the US) are online or intend to be online in the near future. Almost all (95%) said they use the Internet to
access disease information an average of 14.7 times per month, 88% reported reading medical journals online,
and 86% said they use the Internet to obtain drug information.
Of the time spent seeking any information on the Internet, experienced user physicians overall report spending a
full 50% of that time seeking medical information. A finding, both surprising and indicative of the general trend
toward patient empowerment, is that 62% of net-connected physicians reported suggesting to patients that
medical information could be obtained online. Almost one-third of physicians reported that patients had brought
with them medical or health-related information they had found on the Internet [78].
The modernization of public service is a challenge to existing forms of organization in the public health sector
and implies some kind of organizational and personnel change. In fact, technical innovation to a large extent
depends on organizational innovation in order to achieve real improvements in efficiency and quality of service.
Moreover, the potential of health ICT may fall flat without the active involvement of healthcare professionals and
citizens or their representatives in the choice, deployment, and assessment of relevant technologies. For these
user groups to participate in a meaningful way in these procedures they have to be empowered and informed
about the benefits ICT can bring to healthcare delivery.
3.4. New Technologies Require New Skills
People are central in the value-added creation of e-Health products and services and human resource are
crucial to success. The introduction of ICT in healthcare disrupts traditional structures and work organization
requiring that health professionals keep pace with new technologies. Deployment of ICT in a patient care
environment requires that health professionals transcend the strict boundaries of their specialized functions and
acquire a new set of skills that may have been unnecessary in the past. These are mainly leadership
competencies and systemic thinking -- such as strategic and tactical planning, persuasive communication,
negotiating skills, financial decision-making, team building, conflict resolution, and information and knowledge
sharing -- as well as some basic ICT-related technical skills [79, 80, 81, 82, 83]. They create an additional
burden to the already demanding schedule of health professionals.
Education and training are key factors when introducing new methods of work among healthcare providers and
in empowering citizens to access health information. The need to equip healthcare professionals with ICT skills
has been on the educational agenda of many organizations for the past decade. The current expansion of ICT in
the health sector has important implications not only for the support of administrative and functional tasks but
also for the actual delivery of healthcare [7, 20, 21, 40, 41, 49, 76, 84, 85].The nurturing of competencies and
skills and the introduction of new working methods have become key factors in the successful re-engineering of
service suppliers as they transform into agencies providing ICT-enabled services. Changes to strategies,
14
structures, and methods of service delivery are dependent upon a creative and innovative workforce. The latter
needs to adapt skills, competencies and, above all, mindsets and attitudes to new ways of working that are
more responsive to the needs of citizens.
Although technical skills are necessary to set up eHealth applications, the delivery of these applications to
citizens also requires strong inter-personal and managerial skills since quite often providers are required to
manage people over the network. While the technical skills are concerned with the communication technologies
used and the clinical processes enabled by those technologies, the interpersonal skills are concerned with
relationships between system personnel, providers and patients, and the way in which those relationships are
organized. Required skills and competencies can be grouped into the following broad categories [86]:
• Basic computer skills: these include use of computers, web technologies for accessing portals and for using
personalized services, together with eHealth applications for delivering telecare services.
• Organizational and managerial skills: including leadership competencies necessary for the effective
development and delivery of services and for dealing with new organizational structures, service delivery
models, changes in working methods, job roles, etc.
• In-depth understanding of the functional capabilities of eHealth technologies and applications: this
encompasses the ability to have a thorough understanding of how eHealth applications such as integrated
patient management and electronic health records, epidemiological networks, telecare and independent
living devices and services, etc., fit into, and are an integral part of, the formal healthcare delivery system.
• Awareness of legal, ethical, and economic issues surrounding eHealth: this refers to the knowledge and
capabilities that need to be acquired in order to manage the relations between the different stakeholders in
an eHealth environment, such as identifying their rights and obligations, defining service level agreements,
understanding the problems surrounding the security and confidentiality of personal and health data, ways
of preventing and dealing with malpractice, etc.
3.5. Command of Technology and Competitiveness among Care Providers
Many market segments are becoming increasingly ICT-dependent as part of globalization and the success of
developed countries in taking advantage of ICT, particularly the U.S., partly reflects its flexible and competitive
markets. Possibly, smaller benefits can be expected in more regulated economies or in the case of
implementation environments characterized by rigid labor, trade, and inefficient commodity markets,
monopolistic telecommunications sector, and capital exchanges.
Areas of concern in electronic marketplaces, particularly in developing countries, are related to the difficulties in
regulating offshore business, the dominance of the Internet global communications infrastructure by a few
countries, and the growing concentration of power and knowledge in few corporations. As is usually the case
with innovation, the agents that first move into the market quickly attain a dominant position, block the entry of
new competitors, and capture a large part of potential proceeds. Cross-border challenges are particularly
pressing due to the growing number of national, international and non-governmental actors involved in
transnational and global concerns. Market capture by strong, organized, and well-funded health provider
organizations, some of international nature, is happening at a fast pace and regulatory methods have been
advocated to safeguard local competition. Intangible health “e-Solutions” products and services offered by
foreign providers, as is the case of investment, insurance, knowledge dissemination, and healthcare
applications, present possible challenges to developing and poorly developed countries and has resulted in
fears related to flight of capital, tax evasion, employment reduction, capture of the health market, and “cultural
colonization”.
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3.6. Standardization
The simple automation of current processes and services and putting them on a Web-enabled environment is
not feasible without data definition and representation standards. Great amount of work has been done in the
creation and promotion of standards [17, 21, 22, 24, 27, 28, 30, 31, 40, 87, 88, 89, 90]. Process and data
standards for the healthcare industry promoted by accrediting organizations and involving all constituents –
employers, consumers, providers, payers, and regulators – have facilitated the adoption of common procedures
and routines. Despite lack of data standards in some areas, there are solutions that allow different organizations
and systems to communicate through open access Internet-oriented software languages.
A certain amount of standardization also has been driven by regulatory action. In the U.S. the introduction of the
Health Insurance Portability and Accountability Act (HIPAA) regulations forced a reluctant health industry to
adopt uniform formats for health data exchanges and uniform code sets to identify internal and external health
services activities and to be HIPAA-compliant became a requirement of all applications. However, even in
developed countries the lack of national standards for unique person identification has slowed implementation of
patient-based information systems. An extensive review and reference source on healthcare data standards
was published by the Pan American Health Organization [27].
3.7. Security and Privacy
Data security and privacy of personal health data are universal concerns and a high-priority issue in many
countries. There is a growing concern regarding the protection of health records against intrusion, unauthorized
use, data corruption, intentional or unintentional damage, theft, and fraud. Health data transmitted over national
and international networks offer unprecedented opportunities for better patient care and community health
interventions by facilitating data exchange among professionals but pose new challenges to confidentiality. The
promise of Internet to improve care by timely access to the right information can only be realized through secure
connections shared across all platforms.
Given the sensitive nature of healthcare information, and the high degree of health professionals dependence
on trustworthy records, the issues of reliability (data residing in the electronic health record are accurate and
remains accurate), security (owner and users of the electronic health record can control data transmission and
storage), and privacy (subject of data can control their use and dissemination) are of particular significance and
must be clearly and effectively addressed by health and health-related organizations and professionals groups.
Reliability, security, and privacy are accomplished by the implementation of a number of preventive and
protective policies, tools, and actions that address the areas of physical protection, data integrity, access to
information resources, and protection against unauthorized disclosure of information. A comprehensive review
and reference source on personal data protection regulation was published by the Pan American Health
Organization [91].
3.8. Directing and Prioritizing Research and Development
The imbalance between developed and developing countries in terms of biomedical research and technology
adoption is significant and there is great variation in biomedical research productivity among developing
countries. A multiple regression model using research articles publish as indicator and population as the
dependent variable and ten social and economic indicators as independent variables reveals that gross national
product (GNP) per capita and research and development (R&D) expenditure emerged as significant factors [92].
In developing countries, a review of biomedical research articles published during 1990-2000 normalized to
number of publications per million population (PPMP) shows that, in terms of continents, North America had the
highest number of biomedical PPMP per year (341.33); this was followed by Australia and Oceania (288.35),
Europe (136.88), Asia (12.81), South America and Caribbean region (10.80), and Africa (3.50). In total, 52.7% of
the countries showed a positive trend over time: 23.3% in South America, 28.9% in Africa, 40.0% in Australia
16
and Oceania, 61.0% in Asia, 84.6% in Europe, and 100% in North America. All the continents except Africa
showed a significantly positive trend. The better the economic ranking of a country, the higher will be the
number of biomedical PPMP [93, 94].
Science, technology and innovation, used in their broader meaning to include the generation, use and diffusion
of all forms of useful knowledge as well as the evolution of associated institutional arrangements, are an
important component of the global actions directed to meeting the United Nations Millennium Development
Goals (MDGs). A robust science and technology R&D policy cannot exist if it is not underpinned by other well-
designed policies addressing learning, technological development, technology transfer, R&D, and the industrial
and commercial aspects of technological product creation and deployment. This is particularly true in areas that
involve education, health, the social environment, agricultural and medical biotechnologies, pharmaceuticals,
computer networks and telecommunication systems.
Given the fact that the worldwide market for information technology, products, and services is currently valued at
US$853 billion, and that worldwide investment in telecommunications infrastructure is expected to exceed
US$200 billion by 2004, developing countries need to find ways to share this growing trend. Domestic and
foreign, public and private investment sources will be involved, ranging from revenue-sharing initiatives and joint
ventures to direct investment, transfer schemes, development fund established by a special tax on
telecommunications, major private financial institutions, loans from international funding agencies and
development banks, and incentive grants.
4. The International Experience with ICT Integration in the Health Sector
Dating from the mid-1990s there are well-documented studies that demonstrate that ICT enhance productivity in
prominent industries, including wholesale, retail, and services [10, 15, 95]. Similarly, following the introduction of
ICT significant productivity improvement has been corroborated in the massive health sector of developed
countries with significant positive changes in professional productivity; efficiency of interventions; quality of care;
reduction in medical errors; in the expansion of evidence based reasoning; in empowering consumers and
patients; as a catalyst in the establishment of new relationships between patients and health professionals; in
the education of health personnel and citizens; as an enabler of standardized information exchange and
communication; in extending the scope and coverage of healthcare interventions; and in making healthcare
more equitable.
Most of the experience with health ICT originates from Europe, United States, Canada, and Japan. Among
leading digital technologies, Internet-based ICT solutions have brought the greatest impact and they are rapidly
changing the way health organizations, providers, care plans, payers, regulators, and consumers, access
information, acquire health products and services, deliver care, and communicate with each other [7, 9, 20, 76,
96, 97]. Four out of five European doctors have an internet connection, and a quarter of Europeans use the
internet to get information about diseases and health matters. These encouraging figures indicate that ICT-
supported health systems and services will develop rapidly. European Community research funding has
supported health ICT to the tune of EUR 500 million since the early 1990s, with total investment through co-
financing being around twice that amount. Many of today's success stories are the product of that research. All
this has helped to create a new e-Health industry with a turnover of EUR 11 billion. Estimates suggest that by
2010 up to 5% of health budgets will be invested in systems and services.
In the European Union, the development of ICT was conducted since the mid-80’s mostly under the aegis of the
Advanced Informatics in Medicine (AIM) Initiative [98] a multidisciplinary, multiprofessional partnership
dedicated, in association with the health care service, to providing digital based solutions to the problems
encountered in modern health care delivery. Establishment of the Initiative was driven by the realization that the
healthcare sector was introducing ICT tools without adequate research and coordination – this left the sector
17
fragmented and with a great variety of incompatible applications. Managerial and clinical systems were
developed from scratch at local or institutional level or bought from vendors without much consideration for the
emerging unification of the European healthcare systems. Digital diagnostic and therapeutic equipment was
mostly imported from the United States or Japan, the latter taking a leading role particularly in medical imaging.
Funded by the European Community, AIM seeks to encourage research and development in areas of
telemedicine beyond the scope of any one country, or where the expertise of several countries could usefully
come together. AIM is based on a strong academic research infrastructure of experienced scientists and
clinicians and close collaboration with the industry for technology transfer -- the Initiative appreciates that to
secure maximum advantage from scarce research resources, attention must be paid to the potential commercial
exploitation of products and welcomes collaborative arrangements with industry especially those in the
healthcare sector. The Initiative is organized in Framework Programs lasting 2 to 4 years, has hundreds of
partners and participants and funds selected projects in a great number of application areas ranging from
primary care, medical records, coding standards, and decision support systems to instrumentation, multimedia
workstations, and security and data protection.
The main challenge identified in the European Union 2005 e-Health action plan [99] is to improve health and
healthcare through the use of information and communications technologies at a stable or lower cost, and to
reduce waiting times and errors. The aim of the action plan is the creation of a "European e-Health Area" and
identifies practical steps to achieve this by developing electronic systems for health records, patient identifiers
and health cards, and the faster rollout of high speed internet access for health systems to allow the full
potential of e-Health to be delivered. The ultimate aim is for e-Health to become the norm among the healthcare
profession, patients and the general population by the end of the decade.
By end of 2005, each European Union Member State developed a national or regional roadmap for e-Health.
The action plan proposed that the Member States agree by the end of 2006 on a common approach to patient
identifiers and the definition of interoperability standards for health data messages and electronic health records
taking into account best practices, relevant standardization efforts and developments in areas such as the
European Health Insurance Card and identity management for European citizens followed by the deployment of
health information networks for e-Health based on fixed and wireless broadband and mobile infrastructures and
Grid technologies. Considerable investment is required for the development or modernization of systems and
services. Consequently, under the action plan, a collaborative approach to supporting and boosting investment
in e-Health is being undertaken among Member States.
Major efforts are currently underway to establish health information networks. By the end of 2008 the majority of
European health organizations should be able to provide online services such as teleconsultation (second
medical opinion), e-prescriptions, e-referral, telemonitoring and telecare (remote monitoring of patients in their
own homes). It is also expected that the implementation of an electronic health insurance card will be adopted
by 2008. Between 2004 and 2010 the European Commission will publish a biennial study on the progress made
in implementing e-Health.
In the United States and other countries, principal among the factors driving regionalization of care are the
economic forces related to the high cost of many new technologies; superiority of outcomes on the basis of the
experience and volume of cases or procedures; increased diffusion of information and communication
technologies linking providers and support services such as clinical laboratories; public accessibility to health
information; and increased public participation in policy and decision making. Studies conducted in the United
States have shown that the financial differences in managing patient care in various settings are substantial --
US$1,000 to 1,500/day in an acute care facility versus US$48 to 80/day per patient encounter in an ambulatory
care setting. Delays in obtaining laboratory test results may cause patients to receive inappropriate or putting off
appropriate therapy with associated costs to the health care system due to needless medication, and repeat
testing or visits to health care providers, emergency facilities or hospitals. Delayed or lost test results diminish
18
patient compliance, lead to errors in diagnosis, and require physicians to use anticipatory treatment while
awaiting laboratory results. A large base of physicians, particularly in the US, is using the Internet. Physician
usage of the Internet is increasing and almost all physician users are using the Internet for clinical information.
Web-based applications are expanding rapidly and major providers, such as the Cleveland Clinic and the
Kaiser-Permanente Healthcare system in the U.S., have developed incremental approaches to gathering clinical
data, particularly across different organizations and locations. However, a all-or-nothing approach promoted by
some Electronic Medical Record (EMR) vendors and integrated delivery systems has met with limited success
since a “one-size-fits-all” software model is a hard sell to physicians as replacement to the traditional paper
chart, requires a lengthy learning curve, and has a high price tag. At the public health level, it was learned that
useful clinical data can be collected incrementally. For example, for heart failure patients, one item of
information -- the patient's daily weight -- is a reliable predictor of imminent hospitalization. When a patient gains
weight, clinician intervention with medications can often prevent hospitalization. Browser-based technologies are
much more adaptable to individual physician practice patterns. In contrast to earlier applications that required
physicians to adapt to the structure of the software new Web-based approaches bypass the physician -- for
instance, patient education can often be done by "connected" nurses, case managers, or others. In contrast with
past approaches, most are offering physicians carrots, rather than sticks, for their involvement. The rigid
structures of client/server applications and the EMR are giving way to flexible, browser based, work-flow friendly
applications.
5. Health, Poverty, and ICT
Poor health is a major contributor to poverty and good health status is one of the means to prevent poverty and
necessary to overcome poverty and considered an important element on the international poverty reduction
agenda [55, 56, 100]. Approximately 1.2 billion people in the world live in extreme poverty. The vicious cycle of
poverty and illness is well known. The poor live in environments without decent shelter, clean water, or
adequate sanitation that may cause or contribute to ill-health and, on the other hand, sick individuals have
difficulty in keeping jobs. Health and poverty issues are multi-dimensional and markedly differ from country to
country, with countries emerging from and affected by social conflicts presenting a particular challenge.
At the same time, demand for services, the multiplication of expensive diagnostic tools and treatments have led
to ever-growing health costs underlining the urgency of improving healthcare productivity and outcomes;
otherwise, realistically, the expansion of coverage and services of a healthcare system to be able to radically
change the health status of the population in medium and low income countries will be difficult to achieve since
it may threaten the general economic growth by absorbing a significant portion of national budgets.
5.1. The United Nations Millennium Development Goals
The informatics industry, academic institutions, and the health private and public subsectors have proposed that
ICT present unique prospects for the advancement and broadening of the scope and coverage of public health
interventions, particularly among poor and marginalized populations. This role of ICT in improving health actions
directed to the poor is captured in the United Nations Millennium Development Goals, especially in its Target 18:
“In cooperation with the private sector, make available the benefits of new technologies, especially information
and communications” [101, 102]. Furthermore, it is hoped that the strengthening of health systems through ICT
will contribute to the movement toward the achievement of fundamental human rights by improving equity,
solidarity, quality of life, and quality of care ultimately contributing to the goal of poverty reduction.
There is a large body of evidence and experience in the private and public sectors, mostly from developed
countries and well-organized health systems, regarding domains and processes where digital technologies are
seen as highly effective and desirable as enablers of quality of care, as facilitators of equitable access and a tool
19
to support continuity of clinical services sustained by health promotion and maintenance actions involving public
and private stakeholders within a region responsible for the collaborative delivery of a continuum of evidence-
based health services to individuals and communities joined by networked and informed citizens.
Those developed world perspectives, experiences, and strategies are now being proposed as an answer to a
great variety of health system management challenges, poorly developed infrastructures, and other specific
demands faced by developing countries. Certainly a noble-minded ideal but -- as with the whole question of
poverty reduction in general -- how to go about it is still a rather nebulous issue.
5.2. Cautionary Note: A Broader Vision and Scope of Action is Needed
Many externalities constraint development efforts. Knowledge-based systems and technologies are embedded
in a wide array of national institutions – academic, private, and public – that define the scope and use of ICT and
are heavily influenced by political and social priorities issues and by first-movers and their concerns. Producers
and countries may thus not be in full control of how they channel technologies, or in which markets they will be
able to deploy the technologies once they are developed. Because much present technology is both costly and
limited in effectiveness, the greatest challenge in directing development is how to balance external control,
freedom to research, inventiveness, and market forces avoiding the reduction of incentives to innovation to such
an extent that perpetuates the status quo.
The effects of technological innovation are difficult to predict. Besides the intricacies of foreseeing the impact of
innovation, interactions, and new applications of old technologies, they have long-term effects and often present
unintended consequences for equity, health, and well-being of individuals. Technology transfer is neither
costless nor straightforward - the failures of the 60’s and 70’s in technology transfer from industrialized to
developing countries highlighted the over-simplistic models on which these visions were based. Moreover,
reciprocities exist between poverty and ill-health and other social areas such as basic education, sanitation, and
housing.
Perhaps too much faith is being placed in ICT, essentially just a supporting or enabling resource, as solution for
problems that can only be corrected by significant interventions and investments in health service organization,
modalities of health care delivery, infrastructure, reimbursement schemes, and professional and general
population education. Without long-term commitment to those interventions and investments on a national scale
it would be naive to believe that ICT per se will have a significant impact in the improvement of healthcare.
5.3. A National and International Strategy for Health ICT
Joint investment and development involving users, governments, academic and financing institutions and
agencies, technical cooperation agencies, and industry interests are seen as necessary. Partnerships with the
informatics industry are fundamental and, in the case of general informatics tools, the industry practically drives
the solutions. A concerted effort is needed to secure a clearly defined and specified partnership with the
informatics industry at the global and national levels aimed at application development at acceptable cost.
Investments must be attracted to the telecommunications industry by improving investment conditions, lower
duties on telecommunications equipment, and pose no restriction on network design except for technical
reasons to allow for new providers [1, 7, 52, 56, 60, 84, 88, 95, 101, 103].
In the international setting, cooperation between developed and less developed countries is essential but
special care must be taken to avoid interventionist behavior that ignores user’s real needs, fails to understand
host capacities, demands action without allowing sufficient time for conceptual assimilation, neglects cultural
constraints, and ignores host's knowledge basis. As in many other areas of international cooperation the danger
is to have too much too soon or too little too late. A possible framework for collaborative work should include
20
support to international health issues, healthcare reform implementation, application development, education,
and economic and technological cooperation.
Priority areas for international technical cooperation include: priority assessment, technology evaluation and
selection criteria, implementation issues, emerging technologies linking patients and providers, access to
knowledge databases, consumer informatics, and the utilization of Internet and Internet-enabled technologies.
International aspects of e-Health form a critical and urgent area still to be addressed by the World Trade
Organization and regional trade blocks.
By demonstrating that social projects, especially healthcare and education, can be advanced through improved
information infrastructure international technical cooperation and multilateral agencies must collaborate with
national and international authorities and experts to demand that multilateral funding institutions finance large
projects in those areas. Consistent to these objectives, international and multilateral agencies should promote
and support technical cooperation activities involving the transfer of knowledge, technical support, facilitation of
the exchange of experiences between countries, and fostering the use of appropriate technology and knowledge
assets.
Technology assessment methodologies have been proposed and tested for the economic evaluation and triage
and for research prioritization before the funding decision is made. The problem is finding reliable evidence to
support decisions and direct evidence that improvements will occur and are sufficient to meet criteria for cost
effectiveness is commonly absent. Because information on experiences is limited or non-applicable it is not
always possible to carry out pre-project assessment with an acceptable degree of certainty and demonstrating
the cost effectiveness of new technologies is especially challenging in the health sector, where the usual
paradigm of reliance on well-designed and randomized controlled trial is frequently not feasible [104]. Health
organizations in developing countries must be assisted with information about the opportunities as well as the
risks of e-Health solutions. Technology evaluation sources and results must be made available and health
managers must be closely guided in the difficult process of systems specification, procurement, acquisition, and
contracting ICT products and services. The establishment of knowledge repositories in cooperation with the
industry, centers for technology evaluation, academic research groups, and centers of excellence is an
important step in this direction.
5.4. Developing Organizational and Human Resources: Awareness, Skills, and Leadership
Skills are the most expensive and least elastic resource and an obstacle to technological development in
developing countries and success in the deployment of institutional e-Health applications depends on the
existence of staff with the right mix of skills in all functions and at all levels. The number of technicians,
scientists, and portion of the GNP devoted to research and development is a good indicator of those
capabilities. The most successful efforts to incorporate information and communication technologies have
occurred in countries with strong and efficient government and academic institutions committed to invest in
education, scientific and technological development, and public services, in tandem with business sectors ready
and willing to invest in research and development. Skilled professionals in a developing country gravitate to
regions with adequate facilities and enabling environments and regional variations in innovation levels,
technology adoption and diffusion, and institutional mix, all related to the presence of skilled professionals can
be significant even inside a single country.
Human resources development through awareness programs, education of health staff, continuous training, and
career opportunities must be institutionalized from the inception of the developmental effort. Transference of
technical expertise and the appropriation of knowledge by health personnel are necessary for the full
participation of end-users in the development process and the best insurance for successful implementations. A
comprehensive strategy should include:
21
• A structured human resource development program with the goal of increasing awareness of ICT
opportunities and capacitating health professionals to assume a leadership role and actively participate in
all aspects of systems design and implementation.
• A training strategy taking into account issues related to the development and the organizational
environment in which systems are expected to operate and the specific circumstances of the local health
system. Guidelines for training must consider: identify target groups on the basis of functions and training
needs; develop training programs to meet identified needs of target groups; and establish a network of
training focal points, taking into account the national characteristics, and the specific organization and local
health unit workflows and their information requirements.
• Target groups to be considered are: those who originate, collect and supply data; operational decision
makers (direct healthcare professionals and administrators); managers, planners, and policy makers;
information systems managers; information technology and computing specialists; data analysts; and
statisticians and researchers.
• Each country will develop its own strategy for initial and continuing training in health information systems,
considering the overall development of health information systems and its particular healthcare,
educational, research, and market environment.
5.5. Priority Areas for Government Action
Development must be conducted in the context a framework linking public, private, and social efforts to speed
the development of priority ICT solutions. Technical knowledge, experience, and financial investments needed
to establish large and complex information system projects require tapping into resources and expertise that no
organization singly retains. Public and private institutions, academic organizations, the industry, and financing
agents must find ways to pool their assets through project partnerships and add social value to applications of
informatics by providing new employment options, socioeconomic development, educational opportunities,
promoting health, and supporting cost-effective health services.
Priority interventions with high resolution or mitigation are desirable and feasible – effective diagnostic methods
and interventions exist against many widespread health conditions including the limited number of diseases
which account for excessive mortality among the poor [105]. The challenge is finding integrated solutions to
deliver coverage and access to effective healthcare at the client level backed by cost-effective technological
resources that consider the tenets of responsiveness, accountability, and equity with the goal of maximizing
population health and reducing access inequalities
Speeding up adoption depends, however, on the presence of other factors such as incentives, competition,
return on investment, and regulation. Governments must address the establishment of mechanisms to create or
secure a market for new and eventually non-profitable technologies thus reducing the risks involved in R&D and
improving the chances of a satisfactory return on investment and thus influence new technology development
and adoption by the private health subsector. Governments and regulatory bodies have the rationale, the power,
and the opportunity to improve competitive conditions by promoting standards, lessening network externalities at
the community level, and sharpening the private-market competition among providers to use the best and most
efficient solutions.
The attainment of this mandate involves participation of a large number of stakeholders, but the coordinating
effort will necessarily concentrate on the public sector. Governments must grapple with many transnational and
global health ICT issues and address them in a comprehensive and collaborative manner. A major hindrance is
that the current health sector organizational structure and national regulatory framework in developing countries
are not conducive to problem-oriented, interdisciplinary, rapid-response collaborative technical work, and the
22
concomitant implementation of political, regulatory, and managerial tasks required to address multifaceted
complex technological problems.
Six priority areas are envisioned for government involvement in health ICT development and deployment: (a)
promotion of education, training, and national planning capacity in information systems and technology; (b)
convening groups for the implementation of standards; (c) providing funding for research and development; (d)
ensuring the equitable distribution of resources, particularly to places and people considered by private
enterprise to provide low opportunities for profit; (e) protecting rights of privacy, intellectual property, and
security; and (f) overcoming the jurisdictional barriers to cooperation, particularly when there are conflicting
regulations.
6. International Initiatives Promoting Health ICT in the Americas
The Region of the Americas has long recognized the importance of promoting the development of
telecommunications and telecommunication-based technologies as a tool for social development [103, 106] and
the role of ICT was recognized at the Second Summit of the Americas, held in Santiago, Chile in April 1998 as a
solution for strengthening and improving existing national and regional networks of health information and
surveillance systems for clinical and managerial decisions. The background for the recommendations emanating
from the Summit was prepared by Pan American Health Organization [8] and reflected the consensus of
international technical meetings convened by PAHO and by the Inter American Development Bank. The Second
Summit of the Americas Plan of Action addressed the need for (a) the development, implementation and
evaluation of needs-based health information systems and technology that included telecommunications, (b)
support epidemiological surveillance, the operation and management of health services and programs, health
education and promotion, telemedicine, computer networks and (c) investment in new health technologies.
Concerns about the “digital divide” and the social, economic, and national market impacts of the new
technologies and networked global marketplaces have prompted the international community to engage in a
variety of initiatives to harness information and communication technologies for development and establishing
programs aimed at bridging the “digital divide”. In 1999 the United Nations Economic and Social Council
resolved that the high-level segment of its substantive session of 2000 should be devoted to the theme of
information technology in the context of a knowledge-based economy development and international
cooperation in the twenty-first century. The political will of Latin American and Caribbean countries to expand a
knowledge economy was recognized by national leaders has been expressed by leaders during several high-
level meetings. Furthermore, trends in digital convergence occurring between voice and data communication in
telecommunications, telecommunications and broadcasting, and telecommunications and consumer electronics
reinforce the efforts of countries to expand the knowledge economy.
A number of initiatives resulted from the Second and Third Summits, the latter held in Quebec, Canada, in 2001.
Of particular importance are the Agenda for Connectivity in the Americas and Plan of Action of Quito [107]
coordinated by the Inter-American Telecommunication Commission (CITEL).This initiative was presented at the
World Telecommunication Development Conference (WTDC) of the International Telecommunication Union
held in Istanbul, Turkey, in March 2002, which adopted Resolution 39 to include, among the high priorities of
ITU, the support for initiatives under the Agenda for Connectivity in the Americas. The Resolution 39
recommended mechanisms to help achieve the necessary results for each country and region and promote the
exchange of information on the development of global connectivity activities. Subsequently, the Third Regular
Meeting of the CITEL Assembly, held in Washington, D.C., in August 2002, adopted Resolution CITEL/RES. 33
(III-02) on implementation of the Agenda for Connectivity in the Americas, which recognized the Agenda and
Plan of Action of Quito prepared by CITEL as a significant and positive contribution to ongoing efforts to bridge
the digital divide taking place in a number of fora. Aware of the topic high importance, the Plenipotentiary
Conference (PP-02) held in Marrakech, Morocco, in September 2002, in Resolution COM 6/10, lent its support
23
to the proposal in order to build awareness about the impact of telecommunications on national economic and
social development, and its catalytic role in promoting the development, expansion, and operation of
telecommunication services and networks, especially in the developing countries of the Region of the Americas.
CITEL also established a Group for Connectivity Initiatives Management to interact with the ITU/BDT through
the Regional Office of the ITU and with other interested organizations in order to implement projects originating
from these initiatives in the following areas: network infrastructure development; eGovernment; eHealth;
eEducation; eCommerce; training of human resources; eCulture; access to ICT; minorities; persons with special
needs; public protection and disaster relief telecommunications. The countries of the Americas were called upon
to formulate a vision of their national agendas in order to improve the capacity for access to knowledge and
information -- each country being urged, in defining its national vision, to establish realistic objectives and
timeframes. Effective incorporation in this new information and knowledge society will enable the countries of
the region to compete on equal terms and to encourage optimization of the use of limited resources. In the
health sector, CITEL, the International Telecommunication Union, and the Pan American Health Organization
conducted an evaluation of the status of eHealth in the Americas, the incorporation of ICT by the health sector,
an overview of pilot experiences, and a review of trends [52]. Similarly, other agencies have implemented
observatories and clearinghouses on ICT such as the UNESCO Programa para la Sociedad de la Información
en América Latina y El Caribe (INFOLAC), the UN Economic Commission for Latin America and the Caribbean
(ECLAC), and the Institute for the Connectivity in the Americas (ICA). More recently, the Fourth Summit of the
Americas, held in Mar del Plata, Argentina in 2005 reaffirmed the mandates and commitments of the previous
Summits and reiterated the role of the social sectors, health, and technology in the fight against poverty [108].
6.1. The World Health Organization Mandate for eHealth
Since the early 80’s WHO has conducted activities on the use of information technology for health care and
medical purposes [35, 84, 109, 110, 111, 112] -- the Regional Office for the Americas (Pan American Health
Organization), as attested by its extensive list of publications, was an early promoter of ICT in health [8, 9, 19,
26, 27, 49, 91, 106, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130,
131, 132, 133]. WHO recognizes that the emergence and growth of information and communication
technologies, touching many spheres of life, brought opportunities and challenges to all countries and that
eHealth – understood to mean the use of information and communication technologies locally and at a distance
– presents unique prospects for the development of public health. An international consultation convened by
WHO in 1998 [84] prepared input on “telematics” for WHO’s health-for-all policy for the twenty-first century. In
the same year, the Pan American Health Organization Resolution WHA51.9 [134] set out lines of action in
relation to cross-border advertising, promotion, and sale of medical products through the Internet in line with
international efforts on the area.
6.2. Strategic Focus of WHO eHealth Initiative
Member States and groups of Members States are drafting their own strategies for eHealth, and other agencies
of the United Nations system have drawn up strategies for information and communication technologies in their
domains. eHealth was one of the topics discussed at the World Summit on the Information Society held in
Geneva in December 2003 [135] and improving the connectivity of healthcare units was recommended. In view
of the foregoing, the WHO Secretariat prepared a draft strategy for eHealth to serve as basis for coordinating
both eHealth policies internationally and WHO’s activities on eHealth.
The strategy sets the general direction for work in the area, together with specific lines of action and ways of
providing support to Member States in the use of eHealth for public health purposes, healthcare delivery,
capacity building, health education and promotion, and governance. The Fifty-eighth World Health Assembly,
held in May 2005, having considered the report on eHealth [136], and noting the potential impact that advances
in ICT could have on health-care delivery, public health, research and health-related activities for the benefit of
24
both low- and high-income countries and the growing expectations regarding the use of such technologies urged
Member States to (Resolution WHA58.28):
• Draw up a long-term strategic plan for developing and implementing eHealth services
• Develop the infrastructure for information and communication technologies for health as deemed
appropriate to promote equitable, affordable, and universal access
• Built closer collaboration with the private and non-profit sectors
• Promote services oriented towards communities and vulnerable groups
• Mobilize multisectoral collaboration for determining evidence-based eHealth standards and norms, evaluate
eHealth activities, and share the knowledge of cost-effective models
• Establish national centers and networks of excellence for best practice, policy coordination, and technical
support
• Establish and implement national electronic public-health information systems
The Resolution refers to document WHA51.9 on cross-border advertising, promotion, and sale of medical
products through the Internet. The Resolution recommends that eHealth development must respect human
rights, ethical issues, and the principles of equity. Differences in culture, education, language, geographical
location, physical and mental ability, age, and sex will be considered and implementations must include an
appropriate legal framework and infrastructure and encourage public and private partnerships. Recent attention
has been given to the central issue of standardized terminologies [87]. One the Resolution’s immediate result
was the establishment of a Global Observatory for eHealth. The Observatory's mission being to improve health
by providing Member States with strategic information and guidance on effective practices, policies and
standards in eHealth [137] by:
• Providing timely and high-quality evidence and information to help national governments and international
bodies improve policy, practice, and management of eHealth services
• Raising awareness and commitment of governments and the private sector to invest in, and advance,
eHealth
• Collecting, analyzing and distilling knowledge which will make a significant contribution to the improvement
of health using ICT
• Publishing annual report, and special guidelines, on key eHealth research topics as a reference for
governments and policy makers
• Build capacity in eHealth research, analysis and reporting in countries
6.3. eHealth and the Pan American Health Organization (PAHO)
The Strategic Plan 2003-2007 approved by the Pan American Sanitary Bureau (PASB) [44] focuses on
enhancing the Organization’s actions and on the goal of assuming a leadership role in the provision of
information and knowledge relevant to health development needs at national, regional and global levels. The
Plan’s vision is to ensure that all the peoples of the Americas enjoy optimal health and contribute to the well-
being of their families and communities. Challenges that the Strategic Plan addresses include, among others,
25
the urgent issue of globalization, environmental change, and advances in science and technology. These forces
featured significantly in the selection of strategic issues and priorities for technical cooperation for the 2003-
2007 period. Particularly, the Plan recognized that, for the Pan American Health Organization to be able to add
value and increase effectiveness and efficiency of the technical cooperation, the cross-organizational
managerial, technical, and personnel-related issues should be urgently addressed by actions directed toward
the bridging the information divide, maximizing information and communication technology, and harnessing
science and technology. From PAHO’s regional perspective, the WHO Resolution WHA58.28 is understood in
the context of:
(a) PAHO Director agenda regarding the unfinished agenda and new challenges
(b) The challenges of multilingualism
(c) The recommendations of Mexico Summit for actions related to the immediate need to bridge the “know-do”
gap regarding the sharing and application of knowledge
(d) The Millennium Development Goals (MDGs) and its Goal 8, Target 18 that addresses the building of a global
partnership for development in cooperation with the private sector to make available the benefits of new
technologies, especially information and communications
(e) The regional effort to expand and improve existing connectivity, in the framework of the resolutions of the
Summits of the Americas and the Plan of Action of Quito [107]
6.4. Intersection with PAHO’s Knowledge Management Initiative
Public and private organizations and agencies identified Knowledge Management (KM) not merely a latest
management fashion, but as signaling the development of a more organic and holistic way of understanding and
exploiting the role of knowledge in management and work processes, and as an authentic guide for individuals
and organizations in coping with the complex and shifting environment of modern societies [79, 138, 139, 140,
141, 142].
KM is understood as methodologies, processes, and enabling technologies used by managers to allow an

organization, company, or institution to create, collect, organize, share and apply the knowledge it possesses.
KM directly intersects and shares many of the objectives, methodologies, and technological tools of eHealth.
Both consider people, transactions, and added value as the essence – in the case of eHealth, the focus being
the customer/client/citizen and the processes related to the delivery of health actions, the operation of health
systems, and the support of the managerial and educational needs of health professionals. PAHO’s KM strategy
is aligned to the WHO eHealth Resolution WHA58.28 recommendations of:
(a) Promoting international, multisectoral collaboration with view to improving compatibility of administrative and
technical solutions and ethical guidelines in the health sector
(b) Expanding the use of electronic information through the submission of regular reports, documenting and
analyzing developments and trends, informing policy and practice in countries, and reporting regularly on use of
eHealth worldwide
(c) Facilitating the development of model eHealth solutions which, with appropriate modification, could be
established in national centers and networks of excellence for eHealth
26
(d) Providing technical support to Member States in relation to eHealth products and services by disseminating
experiences and best practices, in particular on telemedicine technology, devising assessment methodologies,
promoting research and development, and furthering standards through diffusion of guidelines
(e) Facilitating the integration of eHealth in health systems and services, including in the deployment of
telemedicine infrastructure in countries where medical coverage is inadequate, in the training of health-care
professionals, and in capacity building, in order to improve access, quality, and safety of care
(f) Promoting mechanisms such as the Health Academy, which promote health awareness and healthy lifestyles
through eLearning;
(g) Providing support to Member States in promoting the development, application and management of national
standards of health information and to collect and collate available information on standards aiming at the
establishment of national standardized health information systems in order to facilitate easy and effective
exchange of information among Member States
(h) Supporting the area of eHealth regional and interregional initiatives or those among groups of countries that
speak a common language
7. ICT Integration in the Health Sector of Latin America and the Caribbean
The history of health ICT deployment in developing countries of the Region has been less than stellar.
Notwithstanding the fact that for the past 25 years, the use of computer and telecommunications in health and
healthcare has been a constant item of development agendas, national and international agencies and
multilateral institutions the health sector of Latin America and the Caribbean countries approached the concept
with changing degrees of enthusiasm with periods of great expectations followed by doldrums where
identification of needs and priorities, specification predicaments, technology, costs, and human resources, and
lack of political will and continuity of fledgling initiatives many times pose insurmountable barriers to the
deployment and effective use of ICT.
In the health sector, development and digital divides between industrialized and Latin American and Caribbean
countries is wider than the gap observed in other productive and social sectors. In some cases, the changes
brought about by the privatization of healthcare did add to the already high degree of structural inequity that
prevails in the countries of the Region. The private health sector, insurance companies, group practices, and
other stakeholders rapidly understood the importance of information systems for organizational survival,
competitiveness, and better service and have been at the forefront of ICT and eHealth developments in the
Region.
7.1. Externalities Related to Technology Distribution, Access, and Utilization
Access to technology and related resources represent the most acute issues in the dissemination of eHealth
applications. In a more limited focus, the “digital divide” encapsulates the dramatic worldwide variation in access
to computer-based information technologies, typically measured in terms of teleaccessibility, personal computer
ownership, and internet connectivity available to individuals and communities. There are a large number of
sources and tools for measuring and monitoring technology distribution, access, and utilization including basic
ICT indicators – the International Telecommunication Union and the World Bank being the oldest actors. The
UN Regional Commissions and UNCTAD recently conducted a survey on the status of ICT indicators in 179
countries with the objective of assessing the status of ICT indicators in developing countries [143] and the
situation for the Region in 2005 was compiled by the Observatory for the Information Society in Latin America
27
and the Caribbean using data from different sources and countries, available from public sources such as the
Internet, studies, news media and project reports, and others [144].
Digital divides, like social and economic divides, exist within and not just between societies and are integral
parts of a much broader and intractable “development divide”. Information technology utilization inequalities
found in both industrialized and developing countries are related to level of income and general development,
including determining factors such as insufficient telecommunications infrastructure in poor areas, high
telecommunications tariffs, and uneven ability to derive economic and social benefits from information-intensive
activities. There are today very few technological constraints preventing access to advanced communications
and the Internet, even in the most remote village, through solar-powered satellite dish and portable computers.
The real problem, especially for the cash-constrained health sector, is financial – the capital cost of deploying
the telecommunication infrastructure, particularly fixed lines and fiberoptic cables; processing equipment;
recurrent costs of utilization tariffs; maintenance and upgrading; and training and retaining staff. They prevent
universalization of access as poor countries cannot afford such expenditures.
7.2. Readiness for ICT Incorporation
Countries and communities within countries vary in the ability to incorporate information technology and
telecommunications, in particular interactive communications technologies. The readiness of a country or
community to adopt technological innovation and applications is a complex concept to measure, because the
country may be ready to assimilate some, but not all, technological components and applications. Information
and communication technology metrics is an important tool for the implementation of consistent and comparable
information about diverse systems, platforms, configurations, and application environments.
Indices for measuring ICT diffusion (UNCTAD), opportunity (ITU) and network readiness (Center for
International Development, Harvard University) have been developed with the objective of conducting
systematic comparison of ICT development of countries. An index is considered to be more reliable than a
single indicator in measuring qualitative concepts. This view of a cluster of technologies is consistent with many
studies which suggest that individual technologies need to be evaluated in a context that consider technology as
a multi-faceted concept and the fact that countries seldom exhibit uniform capabilities across the broad
spectrum of ICT [145, 146, 147, 148, 149, 150].The UNCTAD ICT Diffusion Index and has been measured since
1997. The ITU Digital Opportunity index closely matches the UNCTAD ICT Diffusion Index. Recently introduced,
the Center for International Development Network Readiness Index (NRI) was created with the objective of
measuring the preparedness of countries for the networked world.
The NRI has been applied in major international assessment of countries’ capacity to exploit the opportunities
offered by ICT mapping the factors that contribute to this capacity. While any attempt to narrow Networked
Readiness down to a single measure is admittedly artificial, the research performed in the creation of the NRI
has significantly improved the understanding of how different national environments affect the adoption and use
of ICT. The Networked Readiness Index marks an important step forward by distinguishing between factors that
determine the usability of the Network (the Enabling Factors) and variables that reflect the extent of Network
Use. The evidence gathered to date indicates that a high score on Enabling Factors contributes to high levels of
Network Use. However, a high score on Enabling Factors also signals a country’s ability to draw upon existing
ICT networks. The Index signals broad trends, flags opportunities and deficits, and makes a unique contribution
to the understanding of how nations are performing relative to one another with regard to their participation in
the Networked World.
Other indices have been developed: Composite index of technological capabilities across countries (ArCo),
Digital Access Index (DAI), Economist Intelligence Unit (EIU) e-readiness, Index of Knowledge Societies (IKS),
Knowledge Economy Index (KEI), Orbicom Digital Divide Index, Technology Achievement Index (TAI), UN PAN
E-Readiness Index, and the World Bank ICT Index.
28
A critical evaluation of those indices for the Region was recently conducted [151]. Selection of indicators when
building indices; subjectivity; data source, coverage, and validity; and their relative weight when calculating
indices are points of dispute. Conflicting results – ranking high in one index but low in another – demonstrates
how index composition and objectivity vary among indices and suggest that they should be taken with reserve.
All indices show that the countries of Latin America and the Caribbean, with few exceptions, rank low in the
global context but are in line with the level of economic development of the Region but also that the Region
fares well among all developing regions. The Southern Cone presents the highest average score, the worst
being the Andean sub-region. Of particular concern are countries that rank below 80 in the UNCTAD ICT
Diffusion Index (Dominican Republic, Colombia, Guyana, Venezuela, Belize, Panama, Ecuador, Peru, Cuba, El
Salvador, Paraguay, Bolivia, Honduras, Nicaragua, and Haiti. Of concern is also the fact that the evolution of the
indices has been essentially flat or even negative in some countries. Notable improvements were observed in
Chile, Saint Lucia, Jamaica, Brazil, Mexico, Belize, Peru, and El Salvador – those countries showed
improvement of all indices. Chile is the country closest to attain a level comparable to that found in developed
regions.
7.3. The Straggling Public Sector
Despite the fact that the health sector is key to the welfare of the population and the formation of human capital,
the sector has not kept pace with the momentum of change that has been experienced in recent years in other
areas of economic, political, and social life, even in developing countries. Opportunities for ICT deployment have
not been systematically utilized and there are conflicting or misguided perspectives regarding how to bring
technological innovation and integration in an environment of increasing social inequalities and polarization
between local and global values and control.
Unfortunately, the public health sector has lagged behind despite the increasing diffusion of ICT in public
administration and social services. In most countries the public health sector has not applied information and
communication technologies resource, methods, and processes for the day-to-day operation and management
of health systems as effectively as have other sectors of society and health has been conspicuously
underrepresented in national ICT development policies and plans.
Although the view that ICT is essential to the operation and management of health systems is generally
accepted by public sector decision-makers, most projects are under funded, use obsolete technology, have a
restricted vision of requirements and understanding of opportunities, and frequently resort to providers with
limited experience and resources. The justification for the cost-effectiveness of ICT uses in health centers,
hospitals, ministries, health programs, support programs or the national health care service as a whole,
becomes a new challenge every time a deployment is to be assessed, implemented, and sustained in a
particular setting. Finally, public projects take long to implement, cost more, and deliver less than planned.
7.4. Some Decision-Makers Have a Misguided Vision of ICT
Public health authorities invariably declare the criticality of information for decision making and informed action
but repeatedly fail do follow up with the commitment, resources, and sustainability of efforts required for the
deployment of industrial-strength applications. Most existing information systems are inadequate to the
requirements of the new models of healthcare being deployed in the context of health reform initiatives. Besides
the common perception among physicians that health information systems are mostly a source for scientific and
technical information, often public health authorities have a view of clinical-administrative information systems
that is obsolete and frozen in a “statistical-epidemiological” archetype, designed for the collection of numerical
data representing only counts of events and mostly generating only highly aggregated statistical data and time
series related to mortality, morbidity, and to service utilization and coverage. Those information systems have
very little practical interest to direct care professionals and unit managers and are far behind in providing the
29
logistical and longitudinal individual client-based data required to operate and manage the sort of healthcare
models being deployed in many countries.
Until quite recently, many public health authorities were oblivious to the broad variety of possibilities offered by
modern information and communication technologies to manage client-based data, support operations, and
mine large databases. Indeed, the health sector has not applied the range of options provided by information
and telecommunication technologies as effectively as have other social sectors, and health has been
conspicuously underrepresented in national technology development policies and plans. Such concerns have
also been raised by traditional national statistics organizations in developed countries. In the last seven years
there has been encouraging changes in this scenario. Urged by the global progress towards the Information
Society and the promotion of national and regional projects by international and development agencies, many
Latin America and the Caribbean public health organizations are actively engaged in adopting ICT but the
efforts carried in different countries are still restricted to limited application areas, suffer from continuity
breakdowns, and there is very limited intercountry cooperation in the style of the European Union AIM initiative.
Significant examples of public sector leadership and commitment are found in the eLAC2007 initiative involving
the United Nations, the Economic Commission for Latin America and the Caribbean (ECLAC), the EuropeAid
Co-operation Office through the @LIS program, and a number of other national and international technical
cooperation and development agencies.
As a counterpoint to the passiveness of the public sector, the private providers and managed care groups
recognized that a “different” type of information system and data elements are required to run their organizations
and survive in a competitive environment driven by increasing consumer demands and expectations and for the
delivery of personalized evidence-based services. Besides using ICT resources to boost productive
specialization, such as allowing the efficient use of diagnostic services and consultations, the maintenance of
integrated records, reduction in the number of specialists, and attaining economies of scale by linking to national
and international markets, there are many new areas of application that are rapidly gaining ground and reducing
care costs while improving the continuity and quality of care. The lack of involvement of public sector
stakeholders in the use of ICT is worrisome. At a time when, in many countries, the ailing, bureaucratic, and
inefficient public sector is struggling against poorly regulated privatization of social services, there is a clear
danger in that their inaction in adopting ICT solutions may indeed hasten the further reduction and even the
demise of public health services incapable of competing with an IT-enabled private sector.
7.5. Incipient Knowledge Brokering Initiatives
A disconnect between knowledge and its application is a major challenge in the Region. The organizational and
the interpersonal linkages needed to bridge this “know-do gap” are not yet in place, misdirected, or in very early
stage [152]. Governance, organization, and delivery of services reward consensus and lessons learned focused
on local priorities and common standards of practice which are, many times, far removed from the academic
and research environment that provides practically all of the published health technical evidence and research is
often perceived by practitioners as opposite to action, not the antidote to ignorance [153].
The urgent need for knowledge brokers, supported by knowledge brokering resources and agencies is clear –
most of existing knowledge resources are based on repositories of technical and scientific literature and only
recently an effort is being made to implement actionable resources that link researcher to practitioner.
Knowledge brokering is a social solution and human interaction is the engine that drives research into practice.
This linkage model of connecting research evidence to action goes against the predominant view of evidence
informed decision making as a technical exercise with the implicit premise of making compulsory the use of the
clinical guidelines or performance indicators. Rather, it characterizes the task of better informing decisions with
research as being as much social as technical making clinical guideline translation into practice through social
interaction and interpersonal networks. Circulation of knowledge depends on interpersonal networks, and will
only diffuse if these social features are taken into account and barriers overcome. This is a lesson learnt long
30
ago by the pharmaceutical industry, with its use of local opinion leaders to influence patterns of drug prescribing
[154, 155, 156].
In the Region, the Latin American and Caribbean Center for Health Sciences Information (BIREME), a
WHO/PAHO Center, is an outstanding example of what a knowledge broker is expected to be. While keeping
pace with state-of-the-art scientific information, adopting, adapting and developing technologies, standards,
processes, products and services for the countries within this region, BIREME contributes to the continuous
strengthening and improvement of national and regional scientific information produced at local, regional and
national levels. The most relevant feature of BIREME lies in its networking, where national institutions actively
participate based on their political, cultural, social, economic and physical infrastructure and the institution has
radically expanded the inclusion of national institutions and communities in producing, operating and using
cooperative products and services for scientific and technical information.
7.6. Information on Health ICT Projects and Lessons Learned
Information about health ICT projects, methodologies and technical solutions employed, and outcomes is a
major problem in the Region. Until quite recently there have been only sporadic attempts to collect such
information through limited surveys or case studies [38, 52, 125, 157]. Given the need to measure ICT
development, the World Health Organization established a Global Observatory for eHealth and, in the Region of
the Americas, the a joint initiative of the United Nations Economic Commission for Latin America and the
Caribbean (ECLAC) and the Institute for Connectivity in the Americas (ICA) of the International Development
Research Centre of Canada (IDRC) with support from the European Commission @LIS Program crested the
Observatory for the Information Society in Latin America and the Caribbean (OSILAC). Data that follows
originates from those sources.
7.6.1. The PROTIC Projects Database
A major advancement in the collection of project data was the establishment of the PROTIC Projects Database.
PROTIC receives support from the Institute for Connectivity for the Americas (ICA) and of the Economic
Commission for Latin America (ECLAC) through @LIS. The PROTIC database (www.protic.org) has 1,491
projects recorded (May 2007), of which eighty-eight (88) are in the health sector, representing 5.9% of the
database. An analysis of the 88 health projects recorded in the shows:
• Location -- projects were reported in 91 locations, since there were thirteen projects of Regional, four of
Subregional, and one of Global nature representing 19.8% (18/91) of projects. Of national projects 56%
(51/91) were reported in the following countries: Colombia, Peru, Brazil, Venezuela, Argentina, Bolivia,
and Cuba – Colombia being the country with highest number of reported projects (Table 2).
• Project Focus – the objective of 45.5% (40/88) of the projects is to establish a knowledge repository
containing technical and scientific publications, guidelines, best practices, and lessons learned. The
next most frequent objective, representing 15.9% of projects, was to provide access to ICT resources
including training, needs assessment and evaluation, and development of specialized applications. This
is followed by education and prevention applications (13.6%). Only 11.4% (10/88) of projects were
focused in the establishment of direct clinical care, epidemiology, or in-practice education in a patient
care setting (Table 3).
• Health Issues Addressed – the Table 4 lists the spectrum of health thematic areas (areas of application)
for the 88 projects. Nearly half of the projects (47.7%) are related to access to technical and scientific
reference and to clinical care (primary and other levels), family care, immunization, and mental health.
Most of the projects have a public health standpoint and aim at supporting and improving health
interventions and health education.
31
• Project Drivers – regarding the institutional subsector driving the projects, they were categorized in five
classes of institutions: academic; international agency (here understood as national and international
funding organizations, agencies, and multilateral institutions except for UN agencies); private (category
that includes NGOs, foundations, philanthropic organizations, and companies); public; and UN
agencies. Twelve projects have more than one institutional driver. The private sector was found to be
the most frequent driver and present in 31.8% (28/88) of projects followed by international agencies and
the national public subsector, each driving 23.8% (21/88) of projects. The UN agencies drive 20.4%
(18/88) and the academic subsector the remaining 13.6% (12/88) of projects. Only five projects or 5.7%
(5/88) were found to be driven by a public-private partnership. As expected, there major variations
among different countries regarding the mix of driving institutions (Table 5).
• Main Funding Source – sources were categorized in six classes, the only difference regarding the
categorization for project drivers being the distinction in the category UN Agency that was split into two
classes: PAHO and other UN Agencies (Non-PAHO). The public sector was found the most frequent
funding source (31.8% of instances) followed by the Pan American Health Organization (29.5%),
international agencies and private – each representing 26.1%, academic (9%) and other UN agencies
(non-PAHO) funding only 2.2% of projects (Table 5).
Project Location N %
Regional 13 14.3
Subregional 4 4.4
Global 1 1.1
Colombia 11 12.1
Peru 9 9.9
Brazil 8 8.8
Venezuela 7 7.7
Argentina 6 6.6
Bolivia 5 5.5
Cuba 5 5.5
Chile 3 3.3
Ecuador 3 3.3
Mexico 3 3.3
Costa Rica 2 2.2
Dominican Republic 2 2.2
El Salvador 2 2.2
Honduras 2 2.2
Paraguay 2 2.2
Belize 1 1.1
Canada 1 1.1
Guyana 1 1.1
Total 91 100
Table 2. Location of Eighty-eight Health ICT Projects Reported to the PROTIC

Database (May 2007). Source: www.protic.org
32
Project Focus N %
Access to ITC resources and training, connectivity, infrastructure, deployment and needs
8 9.1
assessment, impact evaluation
Application and software development and instrumentation 6 6.8
Basic research 1 1.1
Communication 5 5.7
Community of Practice 2 2.3
Education, Prevention 12 13.6
Evaluation 1 1.1
Health service management 2 2.3
Knowledge repository 17 19.3
Knowledge repository, lessons learned, best practices 23 26.1
Management 1 1.1
Telemedicine clinical care, epidemiology, education 10 11.4
Total 88 100
Table 3. Main Objective (Project Focus) of Eighty-eight Health ICT Projects

Reported to the PROTIC Database (May 2007). Source: www.protic.org
Health Issue Addressed by Projects N %

Access to technical and scientific reference 21 23.9
Clinical care (primary and other levels), family care, immunization, mental health 21 23.9
Access to ICT and e-Health deployment 6 6.8
Environmental health, Water and Solid Waste 4 4.5
Health education, promotion 4 4.5
Professional education 4 4.5
Food safety, Veterinary medicine 3 3.4
HIV/AIDS 3 3.4
Physiological data 3 3.4
Sexual & Reproductive Health 3 3.4
Service management, logistics of patient administration 3 3.4
Drug abuse 2 2.3
Epidemiologic surveillance 2 2.3
None indicated 2 2.3
Disaster prevention & mitigation 1 1.1
Healthy life styles, commercial product promotion 1 1.1
Imaging technology 1 1.1
Neural physiology 1 1.1
Self-help 1 1.1
Traditional medicine 1 1.1
Violence against women 1 1.1
Total 88 100
Table 4. Health Issues Addressed by Eighty-eight Health ICT Projects Reported to the
PROTIC Database (May 2007). Source: www.protic.org
33
Project Drivers Main Funding Source
UN Agency
UN Agency
Non-PAHO
Int Agency
Int Agency
Academic
Academic
Project Location N %
Private
Private
PAHO
Public
Public
Global 1 1.1 1 1
Regional 13 14.1 3 5 1 5 1 6 5 2 1
Subregional 4 4.3 3 1 4
Argentina 6 6.5 1 1 2 1 1 3 2 2
Belize 1 1.1 1 1
Bolivia 5 5.4 2 2 1 1 1 2 2
Brazil 8 8.7 4 3 2 1 2 3 3 1 2
Canada 1 1.1 1 1
Chile 4 4.3 2 1 1 1 1 1 3
Colombia 11 12.0 5 1 4 1 1 3 4 1 3 3
Costa Rica 2 2.2 1 1 1 1 1
Cuba 5 5.4 4 1 1 3 1
Dominican Republic 2 2.2 2 1 1 1
Ecuador 3 3.3 1 2 1 1 1
El Salvador 2 2.2 1 1 1 1
Guyana 1 1.1 1 1
Honduras 2 2.2 1 1 2 1
Mexico 3 3.3 1 1 1 1 1 2
Paraguay 2 2.2 1 1 1 1 1
Peru 9 9.8 2 5 3 1 2 1 5 3
Venezuela 7 7.6 3 3 1 1 3 4
Total 92 100 12 21 28 21 18 8 23 26 23 28 2
Table 5. Institutional Drivers and Main Funding Source in Eighty-eight Health ICT Projects
Reported to the PROTIC Database (May 2007). Source: www.protic.org
Certainly, there are many more projects in operation of being implemented in the Region that are not registered
in the PROTIC database. Hearsay and evidence from meetings and contacts with national professionals
suggest that registration of projects in the PROTIC database must be promoted. The low coverage, already
found in surveys carried in the Region, is a major challenged to be faced if we expect to have a source of project
data and experiences capable of providing a comprehensive view of ongoing health ICT activities.
7.6.2. The 2005 WHO Global eHealth Survey
Data that follows is a tabulation of responses of sixteen countries -- 44% of countries of the Region of the
Americas -- that answered to the WHO Global eHealth Survey 2005 conducted by the Global Observatory for
eHealth, Geneva, in July 2005. The survey collected data on eight dimensions: enabling environment,
infrastructure, content, cultural and linguistic diversity, capacity, and the existence of national centers and
categories of systems and services.
The objectives of the WHO Global eHealth Survey 2005 are to (a) describe and analyze country profiles, (b)
identify and evaluate measures taken by countries in key action areas, and (c) establish the requirements of
34
Member States for tools and services. The Survey responds to issues raised at the Fifty-eighth World Health
Assembly, held in May 2005, WHO Report on eHealth (Document A58/21), and the mandates of the Resolution
WHA58.28.
(a) Enabling Factors: Policies and Strategies
The Tables 6 and 7 tabulate the situation for the existence of key national policy or strategy mechanisms for: (a)
information; (b) ePolicy or eStrategy; (c) eHealth; (d) adoption of eHealth standards; (e) adoption of hardware;
(f) software and content procurement; and (g) health data privacy and security standards, regulations or
legislation. The Tables also list the year in which the policy or strategy was approved or implemented.
Twelve countries informed that a national information policy or strategy is in place (75%). The policy was
implemented in the last three years in five of those countries (41.6 %). The policy or strategy was considered
not or slightly effective by three, moderately to very effective in eight (72.7 %) and five countries did not
respond. Six countries indicated that the policy or strategy will continue the same in the next two years (37.5 %),
six will revise (37.5 %), one will start discussing the issue (BLZ), and two countries are undecided on how to
proceed (HON, SUR).
Thirteen countries informed that a national ePolicy or eStrategy is in place (81.2%). The policy was implemented
in the last three years in seven of those countries (53.8 %). The policy or strategy was considered not or slightly
effective by one, moderately to very effective in nine (69.2 %) and three countries did not respond. Six countries
indicated that the policy or strategy will continue the same in the next two years (37.5 %), six will revise (37.5
%), one will start discussing the issue (COR, and three countries are undecided on how to proceed (CAN,HON,
SUR).
Twelve countries informed that a national eHealth Policy or Strategy is in place (75%). The policy was
implemented in the last three years in three of those countries (25 %). The policy or strategy was considered not
or slightly effective by one, moderately to very effective in nine (75%) and two countries did not respond. Five
countries indicated that the policy or strategy will continue the same in the next two years (41.7 %), six will
revise (50 %), three will start discussing the issue (COR,PAR,PER), and two countries are undecided on how to
proceed (HON, SUR).
Twelve countries informed that national eHealth standards are in place (75%). The policy was implemented in
the last three years in three of those countries (25 %). The policy or strategy was considered not or slightly
effective by one, moderately to very effective in nine (81.2%) and one country did not respond. Twelve countries
indicated that the policy or strategy will continue the same in the next two years (100 %).
Eight countries informed that a health data privacy and security standards, regulations or legislation is in place
(50%). The policy was implemented in the last three years in three of those countries (37.5 %). The policy or
strategy was considered moderately to very effective in four (50%) and four countries did not respond. Seven
countries indicated that the policy or strategy will continue the same in the next two years (87.5 %), three will
start discussing the issue (CHI,DOR,PAN), and four countries are undecided on how to proceed
(ARG,HON,PAR,SUR).
Eight countries informed that procurement policies for hardware, software, and content are in place (50%).
35
Information policy or eHealth Policy or

ePolicy or eStrategy
Countries strategy Strategy
Y/N Year Y/N Year Y/N Year

ARG Y 1997 Y 1997 Y 1997
BAH Y 2003 Y 2000 Y 2000
BLZ N Y 2004 Y 2004
BRA Y 2000 Y 1979 Y 1990
CAN Y 1998 Y 1994 Y 1997
CHI Y 2004 Y 2000 Y 2004
COR N N N
DOR Y 2004 Y 2000 Y 2002
ELS Y 1998 Y 1998 Y 1997
HON N N N
MEX Y 2001 Y na Y 2001
PAN Y 2004 Y 2004 Y 2005
PAR Y 1997 Y 2002 N
PER Y 2003 Y 2005 N
SUR N N N
VEN Y 1978 Y 2001 Y 2002
Table 6. Enabling Factors – Policies and Strategies for 16 Countries of the Americas
Health data privacy

HW,SW,content
eHealth standards & security standards,
procurement policy in
Countries adopted regulations or
health sector
legislation
ARG Y 2000 N N
BAH Y 2002 Y 1995 Y 2003
BLZ Y 2005 N Y 2004
BRA Y 2002 Y 1993 Y 1988
CAN Y 2001 Y 2003 Y 1995
CHI Y 2005 N N
COR Y na N N
DOR N Y 2000 N
ELS Y 1997 Y 1997 Y 1997
HON N N N
MEX Y 2001 Y 1995 Y 2000
PAN Y 2006 Y 2005 N
PAR N N N
PER Y 2000 N Y 2004
SUR N N N
VEN Y 2001 Y 2005 Y na
Table 7. Enabling Factors – Policies and Strategies for 16 Countries of the Americas
36
(b) Funding, Partnerships, and International Cooperation
The Table 8 lists the situation regarding the areas of: (a) provision of public funding of ICT for programs
addressing national health priorities; (b) private funding through grants or private investment for programs
addressing national health priorities; and (c) existence of public-private partnerships to foster the use of ICT
within the health sector. The Table also lists the year in which the policy or strategy was approved or
implemented.
Public-private
Public Funding Private Funding
Countries Partnerships
ARG N N N
BAH Y 1985 N Y 1983
BLZ Y 1998 Y 1985 N
BRA Y 1998 N Y na
CAN Y 1997 Y 1997 Y 1998
CHI Y 2003 N Y 2005
COR N N N
DOR Y 2002 N Y 2004
ELS Y 1997 Y 1997 Y 1998
HON Y 1998 N N
MEX Y 2001 N Y 2000
PAN Y 2005 Y 2000 N
PAR N N N
PER N N N
SUR N Y 2004 N
VEN Y 2001 N Y 2001
Table 8. Funding and Public-Private Partnerships for 16 Countries of the Americas
Eleven countries have public funding (68.7 %), four of those (BLZ,CAN,ELS,PAN) informed that they also have
private funding (25%) and one (SUR) has only private funding. The expectations are that those arrangements
will not change in the next two years. Eight countries indicated that they have public-private partnerships. Of six
countries that responded, five (83.3 %) considered public-private partnerships moderately to very effective.
(c) Inclusiveness, Equity, Multilingualism, and Cultural Diversity
The Table 9 lists the situation regarding the existence of policies in the areas of (a) access inclusiveness and
equity and (b) multilingualism and cultural diversity.
The Table also lists the year in which the policy or strategy was approved or implemented.
37
Multilingualism and
Inclusiveness and equity
Country cultural diversity
Y/N Year Y/N Year
ARG Y 1997 N
BAH Y 1992 Y 1973
BLZ Y 2004 N
BRA Y na N
CAN Y 1985 Y 2003
CHI Y 2003 N
COR N N
DOR N Y 2004
ELS Y 1999 N
HON N N
MEX Y 2000 Y 2001
PAN Y 2005 N
PAR N N
PER N Y 2005
SUR N N
VEN Y 1980 Y 2005
Table 9. Access Inclusiveness/Equity and Multilingualism/Cultural Diversity

Policies in 16 Countries of the Americas
(d) Market Development and Sustainability
The Table 10 displays aggregated data from the WHO Global eHealth Survey related to national ICT in health
development plans; policies on affordability of infrastructure; intersectoral and non-governmental cooperation;
and perceived actions including effectiveness and challenges.
Of the sixteen countries that responded to this survey, only nine have a National ICT in Health Development
Plan, which is slightly over 56%. Of these respondents, five or 56% have said they plan to continue their plan in
the next two years, while four or 44% plan to revise and continue their plan. Three of the countries (BLZ, CHI,
PAN) implemented their National ICT in Health Development Plan during the past three years, and seven (BAH,
BLZ, CHI, DOR, MEX, PAN, VEN) implemented their plan in the last five years. This means 33.3% of the
countries had plans in place for at least three years. The future for the countries without a National ICT in Health
Development Plan is divided. Four of them (Argentina, Costa Rica, Honduras, and Suriname) are undecided
about what to do. The other three (Brazil, Paraguay and Peru) have started to implement their plan. Peru
specifically noted in their survey response that “ESSALUD has a strategic plan for ICT with a technological
calendar.”
Over 55% (BAH, CHI, MEX, PAN, VEN) of the countries with a National ICT in Health Development Plan believe
they are moderately to very effective, while 11% (CAN) found their plan to be extremely effective. However,
about 22% of the respondents (DOR, ELS) said that their plan ranged from not to only slightly effective.
Regarding national policies addressed to the issue infrastructure affordability, six countries out of the sixteen
respondents or 37.5% (BAH, CAN, CHI, MEX, PAN, VEN) have a Policy on Affordability of Infrastructure. Four
or 66% (CHI, MEX, PAN, VEN) have said they plan to continue their policy in the next two years, while two or
33% (BAH, CAN) plan to revise and continue their plan. Three of the countries (CAN, CHI, PAN) had initiated
38
their Policy on Affordability of Infrastructure during the past three years, and five (BAH, CAN, CHI, MEX, PAN)
had initiated their plan in the last five years. Of the ten without a policy on affordability of infrastructure;
Argentina, Costa Rica, Honduras, Peru, and Suriname are undecided about what to do. Brazil, El Salvador,
Paraguay and Peru have started to implement their own policy. Despite participating in this section of the
survey, Belize did not specify their future plans.
Intersectoral and non-

National ICT in Health Policy on affordability of
governmental
Countries Development Plan infrastructure
cooperation
ARG No No No
BAH Yes 2001 Yes 2001 Yes 2001
BLZ Yes 2004 No No
BRA No No Yes Unknown
CAN Yes 2000 Yes 2003 Yes 1995
CHI Yes 2005 Yes 2005 No
COR No No No
DOR Yes 2002 No No
ELS Yes 1995 No Yes 1992
HON No No No
MEX Yes 2002 Yes 2002 Yes 2001
PAN Yes 2005 Yes 2005 Yes 2000
PAR No No Yes 1990
PER No No Yes 2004
SUR No No No
VEN Yes 20013 Unknown Yes 1999
Table 10. National Development Plans and Intersectoral/Non-Governmental

Cooperation for 16 Countries of the Americas
One country (PER) initiated their Policy on Affordability of Infrastructure during the past three years, and three
(BAH, MEX, PER) had initiated their plan in the last five years. However, five countries (CAN, ELS, PAN, PAR,
VEN) had such policies implemented before 2001. Brazil stated they had a policy but did not state what year it
was implemented.
Three countries (BAH, MEX, VEN), which comprises 50% of the respondents with policies on affordability of
infrastructure, believe their plan is moderately to very effective. One country (CAN) found their plan to be
extremely effective. However, one country found their plan not or slightly effective (MEX) and one country
(CHI) stated the effectiveness of their plan was unknown.
Regarding intersectoral and non-governmental cooperation, nine countries out of the sixteen respondents or
56.3% (BAH, CAN, ELS, MEX, PAN, PAR, PER, VEN) indicated to cooperate in the intersectoral and non-
governmental environment. Six or 67% (BAH, ELS, MEX, PAN, PER, VEN) have said they plan to continue
their policy of cooperation in the next two years, while two or 22% (CAN, PAR) plan to revise and continue their
plan. One country or 11% (BRA) is undecided. Of the seven without a policy on intersectoral and non-
governmental cooperation, two countries (HON, SUR) are undecided about what they will do. Two other
countries (ARG, DOR) have started to implement their policies. However, the plans of the remaining three
countries (BLZ, CHI, COR) are unknown. Paraguay (PAR) rates the effectiveness of their policy on intersectoral
39
and non-governmental cooperation as not or slightly effective. Five countries (BAH, ELS, MEX, PAN, VEN),
which comprises 55.6% of the respondents with policies on intersectoral and non-governmental cooperation,
believe their policy is moderately to very effective. Canada (CAN) found their policy to be extremely effective.
However, the effectiveness of the policy in Peru (PER) was stated as unknown.
Out of the sixteen respondents, five countries or 31.3% (ARG, CHI, ELS, MEX, PAN) stated they had
implemented other actions. Three countries or 60% (ARG, CHI, PAN) will continue with them in the next two
years, while two countries or 40% (CAN, PAR) will revise and continue their present actions. There were two
countries or 40% (CHI, PAN) that had started other actions in the last three years. Four of the countries or 80%
(ARG, CHI, MEX, PAN) started such actions in the last five years. One country or 20% (ELS) started earlier than
2001.
(e) Content – Access to Information and Knowledge
Table 11 summarizes the responses of 16 countries in the Region of the Americas on the following topics:
access to international electronic journals, access to national electronic journals, national open archive or
repository policies, and dissemination of health information to the general public. The Table indicates existence
of the access or policy and year it was adopted or started.
Access to International Access to national National Open Archive or Health information for
Electronic Journals electronic journals Repository Policies the general public
Countries
Y/N Year Y/N Year Y/N Year Y/N Year
ARG Yes 2002 Yes 2005 No No
BAH No No No No 2002
BLZ No No No No
BRA Yes 1990 Yes 1997 Yes 1997 Yes 1999
CAN Yes 1993 Yes 1993 Yes 1998 Yes 1997
CHI No No No Yes 2002
COR Yes Unknown Yes Unknown No No
DOR Yes 2002 No Yes 2002 Yes 2000
ELS Yes 1994 Yes 2002 No Yes 2002
HON Yes 2000 Yes 2000 No Yes 2000
MEX Yes 2000 Yes 2000 Yes 2003 Yes 2001
PAN Yes 1999 Yes 1999 No Yes 2005
PAR Yes 2000 Yes 2000 No Yes 2004
PER Yes 2002 Yes 2002 No Yes 2002
SUR No No No No
VEN Yes 2000 Yes Unknown Yes 2001 Yes
Table 11. Information and Knowledge Access Status for 16 Countries of the Americas
Access to International Electronic Journals - Of the sixteen countries that responded to this survey, twelve or
75% have access to international electronic journals. Of these respondents, eight (ARG, BRA, COR, DOR,
MEX, PAR, PER, VEN) or 67% have said they plan to continue offering this access in the next two years, while
four (CAN, ELS, HON, PAN) or 33% plan to revise and continue their current strategy of access.
Access to international electronic journals was started in two of the countries (ARG, DOR) during the past three
years, and three (ARG, DOR, PER) implemented their access in the last five years. This means 16.7% of the
40
countries have had plans in place for at least three years. The remaining four countries who do not have access
to international electronic journals (BAH, BLZ, CHI, SUR) have different plans for the next two years. Bahamas
(BAH) and Chile (CHI) plan to start having access. Suriname (SUR) stated they are undecided, and Belize
(BLZ) did not specify what is likely to happen in the next to years.
Over 75% (ARG, CAN, COR, HON, MEX, PAN, PAR, PER, VEN) of the countries with access to international
electronic journals believe such access is moderately to very effective, while 16.67% (BRA, ELS) found their
plan to be extremely effective. Only the Dominican Republic (DOR) responded that the effectiveness of this
access is unknown.
Access to national electronic journals - Eleven countries out of the sixteen respondents or 68.75% (ARG, BRA,
CAN, COR, ELS, HON, MEX, PAN, PAR, PER, VEN) have access to national electronic journals. Eight
countries or 64% (ARG, BRA, COR, HON, MEX, PAR, PER) responded that they plan to continue their policy of
access in the next two years, while three or 27% (CAN, ELS, VEN) plan to revise and continue their plan.
Panama (PAN) did not specify their plans for the net two years despite participating in the survey. One country
(ARG) or just above 9%had initiated their access to national electronic journals during the past three years, and
three countries (ARG, ELS, PER) which made up just over 27% had initiated their plan in the last five years.
Of the five without access to national electronic journals, three countries (BAH, CHI, DOR) will have started to
implement their own access plan in the next two years. Suriname (SUR) stated they are undecided. Despite
participating in this section of the survey, Belize (BLZ) did not specify their future plans.
Nine countries (ARG, CAN, COR, ELS, HON, MEX, PAN, PAR, PER), which comprises 55.6% of the
respondents with access to national electronic journals, believe having access is moderately to very effective.
One country (BRA) found access to be extremely effective. However, one country found access was not or
slightly effective (VEN) and one country (BRA) stated the effectiveness of access was unknown.
National Open Archive or Repository Policies - Most of the countries did not have national open archive or
repository policies. In fact, eleven countries out of the sixteen respondents or 68.75% (ARG, BAH, BLZ, CHI,
COR, ELS, HON, PAN, PAR, PER, SUR) replied they did not have national open archive or repository policies.
In this case, only five (BRA, CAN, DOR, MEX, VEN) or 31.25% said they have such policies. Out of these five in
the next two years, three or 60% (BRA, DOR, VEN) plan to continue their policies while the remaining two or
40% (CAN, MEX) plan to revise and continue their policies.
One country (PER) initiated their national open archive or repository policies during the past three years, and
three (BAH, MEX, PER) had initiated their plan in the last five years. However, five countries (CAN, ELS, PAN,
PAR, VEN) had such policies implemented before 2001. Brazil stated they had a policy but did not state what
year it was implemented. Of the eleven without national open archive or repository policies, five countries or
45.5% (COR, HON, PAN, PER, SUR) are undecided about what they will do. Five countries or 45.5% (ARG,
BAH, CHI, ELS, PAR) plan to have their policies started. Despite participating in this section of the survey,
Belize (BLZ) did not specify their future plans.
Three countries (CAN, MEX, VEN), which comprises 60% of the respondents with national open archive or
repository policies, believe their policy is moderately to very effective. Brazil (BRA) found their policy to be
extremely effective. However, the effectiveness of the policy in Dominican Republic (DOR) was stated as
unknown.
Health information for the general public - Most of the countries did have health information for the general
public. In fact, eleven countries out of the sixteen respondents or 68.75% (BRA, CAN, CHI, DOR, ELS, HON,
MEX, PAN, PAR, PER, VEN) replied they did have health information for the general public. In this case, only
five (ARG, BAH, BLZ, COR, SUR) or 31.25% said they did not have such policies. Out of the eleven countries
41
who did have information for the general public, in the next two years, seven or 64% (CHI, DOR, MEX, PAN,
PAR, PER, VEN) will continue their policies while the remaining four or 36% (BRA, CAN, ELS, HON) plan to
revise and continue their policies.
Two countries (PAN, PAR) initiated their health information for the general public policies during the past three
years, and seven (BAH, CHI, ELS, MEX, PAN, PAR, PER) had initiated their plan in the last five years. Three
countries (BRA, CAN, DOR, HON) had such policies implemented before 2001. Venezuela (VEN) stated they
had a policy but did not state what year it was implemented. Of the eleven without health information for the
general public policies, two countries or 40% (ARG, SUR) are undecided about what they will do. Two countries
or 40% (BAH, COR) plan to have their policies started. Despite participating in this section of the survey, Belize
(BLZ) did not specify their future plans.
Seven countries (BRA, CHI, ELS, MEX, PAN, PER, VEN), which comprises 63.6% of the respondents with
health information for the general public policies, believe their policy is moderately to very effective. Canada
(CAN) found their policy to be extremely effective, while Honduras (HON) and Paraguay (PAR) considered their
policy to be only slightly effective. However, the effectiveness of the policy in Bahamas (BAH) was stated as
unknown.
(f) Country Perceptions of Most Important Challenges and Most Effective Actions
Tables 12 and 13, respectively, summarize the actions found to be most effective and the most important
challenges to be overcome regarding access to information and knowledge.
MOST EFFECTIVE ACTIONS

ARG To date the most effective action has been the digital library, which provides access to the complete texts of
science reviews for all national universities and research institutes.
The Scielo Program ("Reach for the Sky with Science") is also yielding positive results in Argentina, including on-
line open access to the country's leading health reviews. However, having only started this year, it is still in its
nascent phase.
BRA • The Virtual health Library project (BVS): promotion of inter-institutional partnerships for the production of health
information;
• Scielo (electronic journals portal): comprehensive and open scientific content;
• Capes portal: makes international journals available free of charge to all Brazil's teaching institutions;
• Health portal: (Ministry of Health).
CAN For approximately 10 years, Canada has successfully worked with its citizens, including voluntary and community
groups, to identify and post electronic health information that is relevant to the public and reflects the various
literacy levels. This has been particularly important for those citizens whose first language is not English or
French.
Through the multi level approaches and partnerships awareness building exercises, access to authoritative and
appropriate eHealth information has risen substantially within the last six years. Partnerships with community
groups, seniors centers, and the various educational institutions ranging from public schools to Universities
training future health practitioners have ensured that consumer education focuses on being aware that the
health-related information a consumer accesses is accurate as opposed to being commercially motivated, and
that it has been reviewed by appropriate experts. In 1999, approximately 5,000 nonfederal government
resources were identified, made accessible through federally funded sites, and accessed by approximately
200,000 visitors. In 2005, this collection had risen to more than 19,000 nonfederal current and authoritative
resources with over 1 million unique visitors per year.
The Canadian Women’s Health Network (CWHN) facilitates national networking of women’s health organizations
in Canada. The purpose of the Network is to communicate the research findings of the Centers of Excellence for
Women’s Health and other initiatives by means of a monthly e-bulletin on women’s health issues each month.
CWHN’s extensive database serves as a virtual clearinghouse with a website of 2,000 pages, used by about 1
42
million visitors monthly. Besides information in English and French, some postings include up to 40 other
languages.
COR 1. The most effective action has been development of the Scielo Costa Rica project and the production of
electronic versions of national reviews not included in that project. This has been so effective because users are
able to access full text without the needing to go to the information units and with no time limit.
2. Development of web sites of health-sector institutions, such as CCSS, the Ministry of Health, the Institute of
Statistics and Censuses, the Central American Centre for Population, the Costa Rican Cancer Institute, and the
Social Security Virtual Health Library.
DOR Development of the national virtual health library (BVS), which is the fruit of efforts by 19 institutions in the health
and health and environment sectors. Thanks to this library, information produced in these areas in the country is
available and accessible in electronic format.
ELS Most effective action
El Salvador is developing and improving information systems to facilitate and encourage their use, although this
is essentially being done on a sector-by sector basis.
Reasons why this is effective
As these concerns a number of sectors in the country, it has been effective mainly because it has raised the
profile of the topic and because financial resources have become available.
The strengthening of a number of sectors in this field is tangible proof of the importance and usefulness of
information and communication technology. In addition, this is the starting point for nationwide dissemination of
ICT.
HON The creation of the Virtual Health Library of Honduras, sustainability, cooperative work of various institutions,
national initiative, not institutional, institutional commitment.
MEX Upgrading information technology and telecommunications in order to improve the health services provided to the
population, and in particular to marginalized and vulnerable groups.
The eHealth portal was developed, the first portal for the general public to be developed by the health sector in
Mexico. This focused the sector's attention on the topic. Since the launch of this portal, the following initiatives
have got under way.
1. An institutional page: "Advice on health care and prevention from ISSSTE"
2. A section entitled "How can we look after our health?" on the page of the national public health institute.
3. Creation the IMSS journal "Here's to your health"
PAN Technological strengthening of the web of the Ministry of Health and the insertion within the organization
PAR Integration of the network of the Virtual Health Libraries with the opportunity to utilize technological
methodologies to register and access different data bases.
PER Issuance of the Law of "Governmental Transparency" (Law 27806/2002)
VEN The development and sustainability of networks like the VHL (Virtual Health Library) and SciELO (Scientific
Electronic
Library Online), which enable equitable and free access to health information.
Table12. Most Effective Actions and Important Actions Identified by 16 Countries

that Responded to the WHO Global eHealth Survey
MOST SIGNIFICANT CHALLENGES

ARG The most significant challenge is funding, given that the cost of access to international science reviews is very
high for our country. In this regard, purchasing joint subscriptions for the entire scientific community via the digital
library has yielded positive results, although it has not solved the problem entirely.
BEL It has not been considered a priority.
BRA • Lack of high-quality connectivity;
• Shortage of computers in universities and research institutes;
• High cost of subscriptions to journals;
• Resistance to the computer culture;
• Computer illiteracy
43
CAN Having built a myriad of websites and resources (by federal, provincial/territorial governments, voluntary groups,
public health associations) that provide electronic health content to citizens over the last ten years, Canada’s
challenge now is to find a way to ‘harmonize’ all the information now available online.
This information is currently offered through multiple levels of government as well as non-government
organizations including professional associations, volunteer organizations, private and corporate enterprises etc.,
but few use the same platform or infrastructure. The challenge therefore lies in ensuring that users can access
the information, regardless of the level of technology they have available to them, and in finding ways to ensure
that the information is ‘seamless’ and easy to use.
Projects working toward ‘harmonization’ of various federal government-sponsored websites are underway, and
will continue.
2. The many languages in use in Canada other than French and English pose an ongoing challenge. As noted
above, some provinces with large non-English speaking populations (e.g. Ontario, British Columbia) have been
working diligently to meet this challenge. Most government sites highlight health materials developed in other
languages as options.
3. Canada’s diversity is not limited to language – differing cultural and religious beliefs are also a factor. Since
information on health choices for all groups in Canadian society must be presented on government-sponsored
websites, this may include information about health care procedures and practices (e.g. birth control) with which
some groups in Canada may disagree, no matter how factually accurate the information presented. Website
managers deal with these issues in the same way as they handle other questions from the public.
COR 1. The main challenge is that many health workers lack access to the Internet.
2. The lack of high-speed communications media and the cost of equipment. We have addressed this via
projects to improve communications facilities through the Costa Rican Electricity Institute.
DOR The main challenge has been the difficulty in ensuring regular collection of information in electronic format
because of the absence of an appropriate national policy.
Nevertheless, BVS and BVSA are tools which may be used to improve this situation.
ELS Main challenge.

Some sectors in El Salvador are somewhat reluctant to share information because there are still shortcomings in
data analysis. Few sectors have access to or the resources required by this type of system.
HON The shortage of infrastructure and connectivity. It has been confronted with alternative information products: CD-
ROMs for communities without access to the Internet, increased awareness of the decision makers to equip the
documentation centers and libraries with ICT.
The lack of professionals in the area of information management.
MEX Lack of sufficient Internet access. Providing the population with shared access, for example via Internet kiosks
Development of content intended for the population
PAN Resistance to change
Lack of human resources training
PAR Expensive equipment, high Internet service costs, slowness of the servers in the country and lack of training of
the human resources.
PER a) There is no culture of systematic diffusion of technical information on health that is politically sensible, like the
publication of indicators for the fulfillment of health goals
b) Only 7% of the homes have access to computers and it is estimated that in 2005, only 1% of the homes have
access to the Internet.
VEN The limited budget for this in national universities, the inexistence of consortia for acquiring journals and the per
capita income of Venezuela make it impossible to access the Health InterNetwork Access to Research Initiative
(HINARI).
Table 13. Most Important Challenges Identified by 16 Countries

that Responded to the WHO Global eHealth Survey
44
(g) Cultural and Linguistic Diversity
Table 14 provides an overview of the creation and dissemination of electronic health content in local languages,
which recognizes and promotes cultural diversity. Cultural diversity is an essential factor in promoting cultural
identity and linguistic diversity in an information society. More specifically, the table lists the existence of – (a)
multilingual projects; (b) translation and cultural adaptation; and (c) other actions, as well as the year in which
the policy or strategy was approved or implemented.
Multilingual projects Translation and cultural

Other Actions taken
Countries adopted adaptation implemented

ARG N N N
BAH N N N
BLZ N N N
BRA N Y 1985 N
CAN Y 2004 Y 1997 Y 2001
CHI N N N
COR N N N
DOR N N N
ELS N N N
HON N N N
MEX Y 2000 Y 2003 N
PAN N N N
PAR N N N
PER N N N
SUR N N N
VEN Y 2004 Y na N
Table 14. Cultural and linguistic diversity, and cultural identity

Strategies for 16 Countries of the Americas
Three countries informed that they have introduced special projects to promote the development and use of new
electronic health content in multiple languages -- multilingual projects (18.75%). These projects were adopted in
the last three years in two of the three countries (66.67 %) and in the last 5 years in the remaining country
(33.33%). The multilingual projects were considered not or slightly effective by one country (33.33%) and
moderately to very effective in the remaining two countries (66.67 %). One country indicated that the multilingual
project implementation process will continue the same in the next two years (33.33 %), while two countries
(66.67 %) will revise it and continue. Of the thirteen countries that have not yet adopted and implemented
multilingual projects, ten are undecided on how to proceed (ARG, BAH, BRA, CHI, ELS, HON, PAN, PAR, PER,
and SUR), one will start to implement them (DOR) and two have not replied (BLZ, COR).
Four countries informed that they support the translation and cultural adaptation (localization) of existing high-
quality content which has been created either locally or abroad --translation and cultural adaptation (25%). The
translation and cultural adaptation policy was implemented in the last three years in one of these countries
(25%) and in the last five years in two other countries (50%). The date of implementation in the fourth country
(VEN) is unknown. The translation and cultural adaptation policy was considered not or slightly effective by one
country, moderately to very effective by two (50%) and extremely effective by one country. One country
indicated that the policy will continue the same in the next two years (25%) and three responding countries will
revise it and continue (75 %). Of the twelve countries without a translation and cultural adaptation policy, nine
45
countries are undecided on how to proceed (ARG, BAH, CHI, ELS, HON, PAN, PAR, PER, and SUR), one has
started to implement (COR), one will continue the same (DOM) and one has not replied (BLZ).
One country (CAN) informed that it is taking Other Actions on Cultural and Linguistic Diversity and Cultural
Identity (6.25%). These actions were implemented within the last 5 years and are considered moderately to very
effective. CAN indicated that it will revise these actions and continue. The remaining fifteen countries that
provided answers to the previous sections of this chapter on Cultural and Linguistic Diversity and Cultural
Identity did not identify any Other Actions they are taking with respect to Cultural and Linguistic Diversity and
Cultural Identity.
(h) Human Resources and Skills
Table 15 lists the situation for the existence of key national policy or strategy mechanisms (a) undergraduate or
post training graduate training on ICT, (b) continuing education on ICT, and (c) eLearning in health sciences. In
addition, it highlights the year in which the policy or strategy was approved or implemented.
Seven countries informed that a policy on undergraduate or post graduate training on ICT is in place (43.75%).
The policy was implemented in the last three years in two of those countries (28.57 %). The policy or strategy
was considered not or slightly effective by two, moderately to very effective by three (42.86 %) and two
countries did not respond. Five countries (ARG, PAN, PER, SUR, VEN) indicated that the policy or strategy will
continue the same in the next two years (71.43 %); two countries (BRA, CAN) will revise and continue (28.57
%). Of the nine countries without policy on affordability of undergraduate or post graduate training on ICT, four
countries are undecided on how to proceed (CHI, ELS, HON, PAR), two countries have started to implement
(BAH, MEX) and one has not replied (BLZ).
Undergraduate or post
Continuing education eLearning in health
graduate training on
Countries on ICT sciences
ICT
ARG Y 2005 Y 2005 Y 2001
BAH N Y 1980 N
BLZ N N N
BRA Y 1983 Y 1986 Y 1996
CAN Y 1997 Y 1997 Y 1997
CHI N N Y 2003
COR Y na N Y na
DOR N N Y 2002
ELS N Y 1990 Y 2000
HON N N Y 2004
MEX Y 1996 Y 2001 Y 2001
PAN Y 2004 N N
PAR N N N
PER Y 2002 N N
SUR Y 1983 N N
VEN Y na Y na Y 2005
Table 15. Human Resources Knowledge and Skills

Policies and Strategies for 16 Countries of the Americas
46
Seven countries informed that a policy on continuing education on ICT is in place (46.67%). The policy was
implemented in the last three years in one of those countries (14.29 %). The policy or strategy was considered
not or slightly effective by one, moderately to very effective by five (83.33 %). Three countries (ARG, BAH, VEN)
indicated that the policy or strategy will continue the same in the next two years (42.86 %) and four countries
(BRA, CAN, ELS, MEX) will revise and continue (57.14 %). Of the eight countries without a policy on
affordability of continuing education on ICT, four countries are undecided on how to proceed (CHI, HON, PAR,
and SUR), two countries have started to implement (COR, PAN) and one country has not replied (BLZ).
Nine countries informed that a policy on e-learning in health sciences is in place (56.25%). The policy was
implemented in the last three years in three of those countries (33.33 %). The policy or strategy was considered
not or slightly effective by none of the countries, moderately to very effective by nine (90%) and one country did
not respond. Six countries (ARG, BRA, DOR, HON, MEX, VEN) indicated that the policy or strategy on e-
learning in health sciences will continue the same in the next two years (66.67 %) and three countries (CAN,
CHI, ELS) will revise and continue (33.33 %). Of the seven countries without policy on affordability of e-learning
in health sciences, two countries are undecided on how to proceed (PER, SUR), three countries have started to
implement (BAH, PAN, PAR) and one country has not replied (BLZ).
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1

ICT in Health (R.J.Rodrigues), Version 2

Information and Communication Technologies in Health Practice

• Growth of complex and segmented health service markets

• Growing importance and need for professional continuing education

• Need for rapid responses and forecasting demand

1. Medical, Social, Economic, and Organizational Issues in the Health Sector

1.1. Healthcare Services in Latin America and the Caribbean

1.2. Reforming the Health Sector

• Cost containment and recovery;

• Administrative decentralization and operation of healthcare services;

• Health models oriented towards primary care and centered on people;

• Focus on quality and accountability; and

2. Information and Communication Technologies in the Health Sector

2.1. ICT in the Context of Healthcare Technologies

• Diagnostic Technology - such as electrocardiography, electroencephalography, myography, x-ray imaging,

• Therapeutic Technology - including curative and preventive technologies such as pharmaceuticals,

2.2. Evolution of ICT Applications in Health Practice

• C LINIC AL C OS TIN G • RE S OU RC E • DIS TR IBU TE D

• S IM P LE CLIN ICAL • OP E R ATION S • RE S OUR C E

O PER AT IO N A L DET ERM IN A NT S

Figure 1. Over the Past Four Decades Health Applications of Information

2.3. ICT and Health Sector Management and Operation

2.4. Matching ICT Applications to Health Sector Requirements

• Economies of speed associated to economies of scale

• Custom-built products and services (“individualization of care”)

• Convenience and “real time” processes (“customer satisfaction”)

• Capturing and sharing the tacit knowledge of health professionals

• Modularity and standardization of basic components (“reuse”)

• Evidence-based justification for deployment and utilization of new technologies

• Safety, confidentiality (“data protection”), and regulatory concerns

2.5. From Health ICT to e-Health

• Equity – aiming at making healthcare more equitable.

eHealth applications have been deployed in the following areas [7]:

• Professional Communication among Providers

2.6. Market for ICT Products and Services

Number Hospitals Beds

1-50 10,027 60.5 219,383 20.0

Sub-Total 15,479 93.4 1,097,965 100

Table1. Hospitals in Latin America and the Caribbean by Number of Beds

2.7. Presence of an Enabling Organizational and Governance Environment

3. Technological Innovation and Acceptance in the Health Sector

Technology-driven innovation is a multiple-step interactive process requiring attention to constantly changing

3.2. The Anti-technology Prejudice

3.3. Development and Adoption of Innovation by the Health Sector

3.4. New Technologies Require New Skills

3.5. Command of Technology and Competitiveness among Care Providers

3.7. Security and Privacy

3.8. Directing and Prioritizing Research and Development

4. The International Experience with ICT Integration in the Health Sector

5. Health, Poverty, and ICT

5.1. The United Nations Millennium Development Goals

5.2. Cautionary Note: A Broader Vision and Scope of Action is Needed

5.3. A National and International Strategy for Health ICT

5.5. Priority Areas for Government Action

6. International Initiatives Promoting Health ICT in the Americas

6.1. The World Health Organization Mandate for eHealth

6.2. Strategic Focus of WHO eHealth Initiative

• Built closer collaboration with the private and non-profit sectors

• Promote services oriented towards communities and vulnerable groups

• Establish and implement national electronic public-health information systems

• Build capacity in eHealth research, analysis and reporting in countries

6.3. eHealth and the Pan American Health Organization (PAHO)

(b) The challenges of multilingualism